Healthcare Provider Details

I. General information

NPI: 1407889967
Provider Name (Legal Business Name): HANNAH C SULLIVAN LMSW, LMFT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/08/2006
Last Update Date: 08/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 KRAFT AVE SE SUITE 186
GRAND RAPIDS MI
49512
US

IV. Provider business mailing address

1314 CALVIN AVE SE
GRAND RAPIDS MI
49506-3212
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-9550
  • Fax: 616-949-9551
Mailing address:
  • Phone: 616-235-2090
  • Fax: 616-235-2099

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801085815
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: