Healthcare Provider Details

I. General information

NPI: 1720412455
Provider Name (Legal Business Name): ANN ELLEN SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/29/2013
Last Update Date: 08/20/2026
Certification Date: 08/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 CREEKSIDE OFFICE DR
WENTZVILLE MO
63385-3290
US

IV. Provider business mailing address

2 MACON CT
LAKE ST LOUIS MO
63367-1226
US

V. Phone/Fax

Practice location:
  • Phone: 636-202-1412
  • Fax: 636-201-3379
Mailing address:
  • Phone: 903-357-9642
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number6286
License Number StateOK
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number2019046362
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: