Healthcare Provider Details

I. General information

NPI: 1619707932
Provider Name (Legal Business Name): CONNOR SULLIVAN MSW, PLMHP, PCMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2024
Last Update Date: 05/10/2026
Certification Date: 05/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4316 S 48TH ST STE 2
LINCOLN NE
68516-1287
US

IV. Provider business mailing address

4316 S 48TH ST STE 2
LINCOLN NE
68516-1287
US

V. Phone/Fax

Practice location:
  • Phone: 402-205-7976
  • Fax:
Mailing address:
  • Phone: 402-205-7976
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number14213
License Number StateNE
# 2
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number8129
License Number StateNE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: