=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831258979
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHERRY DENISE SULLENS MA, LPC, CADCII
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/06/2006
-----------------------------------------------------
Last Update Date | 04/11/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 182 SW ACADEMY ST
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97338-1996
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-831-5970
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12505 AIRLIE RD
-----------------------------------------------------
City | MONMOUTH
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97361-9765
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 971-241-8680
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YP2500X
-----------------------------------------------------
Taxonomy Name | Professional Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------