Healthcare Provider Details

I. General information

NPI: 1881974780
Provider Name (Legal Business Name): AMALIA SULLIVAN LCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/23/2011
Last Update Date: 02/27/2023
Certification Date: 02/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 CHAUCER CT
EUGENE OR
97405-1217
US

IV. Provider business mailing address

2520 CHAUCER CT
EUGENE OR
97405-1217
US

V. Phone/Fax

Practice location:
  • Phone: 541-203-6703
  • Fax: 541-229-1209
Mailing address:
  • Phone: 541-203-6703
  • Fax: 541-229-1209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number7561
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier500663904
Identifier TypeMEDICAID
Identifier StateOR
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: