Healthcare Provider Details

I. General information

NPI: 1215591334
Provider Name (Legal Business Name): HEATHER M SULLIVAN LISW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
DAYTON OH
45433-5529
US

IV. Provider business mailing address

4881 SUGAR MAPLE DR
DAYTON OH
45433-5529
US

V. Phone/Fax

Practice location:
  • Phone: 937-522-2778
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number2607647
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: