Healthcare Provider Details

I. General information

NPI: 1710692678
Provider Name (Legal Business Name): OLIVIA SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2023
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3011 N MICHIGAN ST
PITTSBURG KS
66762-2546
US

IV. Provider business mailing address

PO BOX 1832
PITTSBURG KS
66762-1832
US

V. Phone/Fax

Practice location:
  • Phone: 620-231-9873
  • Fax: 620-231-5062
Mailing address:
  • Phone: 620-240-5668
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number03215
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number04351
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: