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General NPI Number Information
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NPI Number | 1134110760
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Entity Type | Individual
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Provider Name | MICHELLE P SULLIVAN LCSW
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Gender | Female
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Dates
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Enumeration Date | 11/02/2005
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Last Update Date | 03/10/2014
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Provider Practice Location Address
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Address Line | 4700 NORTH LAS VEGAS BOULEVARD MIKE O'CALLAGHAN FEDERAL MEDICAL CENTER
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City | NELLIS AIR FORCE BASE
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State | NV
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Zip | 89191-6601
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Country | US
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Telephone | 702-653-3455
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Fax | 702-653-3398
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Provider Business Mailing Address
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Address Line | 4700 LAS VEGAS BLVD N MIKE O'CALLAGHAN FEDERAL MEDICAL CENTER
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City | NELLIS AFB
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State | NV
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Zip | 89191-6600
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Country | US
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Telephone | 702-653-3455
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Fax | 702-653-3398
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 104100000X
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Taxonomy Name | Social Worker
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License Number | CW014390
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License Number State | PA
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