Healthcare Provider Details

I. General information

NPI: 1730947599
Provider Name (Legal Business Name): THEODORE SULLIVAN LMHC, LCPC, LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: TEDDY SULLIVAN LMHC, LCPC, LPC

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 08/04/2026
Certification Date: 08/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1487 N BRUMMITT RD
CHESTERTON IN
46304-8710
US

IV. Provider business mailing address

1487 N BRUMMITT RD
CHESTERTON IN
46304-8710
US

V. Phone/Fax

Practice location:
  • Phone: 219-386-3296
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number39005758A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number101056
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number180.018283
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: