Healthcare Provider Details

I. General information

NPI: 1750580825
Provider Name (Legal Business Name): MICHELLE SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 09/02/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 S 8TH ST
YAKIMA WA
98901-3020
US

IV. Provider business mailing address

PO BOX 2605
YAKIMA WA
98907-2605
US

V. Phone/Fax

Practice location:
  • Phone: 509-454-4143
  • Fax: 509-454-3651
Mailing address:
  • Phone: 509-454-4143
  • Fax: 509-454-3651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberLH60156441
License Number StateWA
# 2
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License NumberRC00041146
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: