Healthcare Provider Details

I. General information

NPI: 1063561447
Provider Name (Legal Business Name): JOHN W SULLIVAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 LAKE BOONE TRL
RALEIGH NC
27607-2934
US

IV. Provider business mailing address

6609 MOUNTAIN BROOK DR
RALEIGH NC
27615-7307
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-9182
  • Fax: 919-784-9184
Mailing address:
  • Phone: 919-844-1649
  • Fax: 919-844-1649

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number5497
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: