Healthcare Provider Details

I. General information

NPI: 1740367291
Provider Name (Legal Business Name): REBECCA SULLIVAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 03/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 N 18TH ST SUITE 101
LAFAYETTE IN
47904-3410
US

IV. Provider business mailing address

615 N 18TH ST SUITE 101
LAFAYETTE IN
47904-3410
US

V. Phone/Fax

Practice location:
  • Phone: 765-423-5361
  • Fax: 765-742-8272
Mailing address:
  • Phone: 765-423-5361
  • Fax: 765-742-8272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number34003487
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: