Healthcare Provider Details

I. General information

NPI: 1003101577
Provider Name (Legal Business Name): SULLIVAN MENTAL HEALTH SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2011
Last Update Date: 11/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S WOODRUFF AVE
IDAHO FALLS ID
83401-5299
US

IV. Provider business mailing address

660 S WOODRUFF AVE
IDAHO FALLS ID
83401-5299
US

V. Phone/Fax

Practice location:
  • Phone: 208-523-1558
  • Fax: 208-529-4788
Mailing address:
  • Phone: 208-523-1558
  • Fax: 208-529-4788

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number
License Number StateID
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number
License Number StateID

VIII. Authorized Official

Name: MRS. JESSIE ELAINE SULLIVAN
Title or Position: OWNER/THERAPIST
Credential: LCPC LMFT
Phone: 208-523-1558