MEDICARE: ANNE D SULLIVAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YM0800X	Mental Health Counselor

General Provider Information

NPI Number	:	1083883920
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNE D SULLIVAN

Provider Business Mailing Address
First Line	:	605 SE CESAR E CHAVEZ BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-3216
Country	:	US
Telephone Number	:	503-314-9816
Fax Number	:

Provider Business Practice Location Address
First Line	:	605 SE CESAR E CHAVEZ BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97214-3216
Country	:	US
Telephone Number	:	503-731-9581
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/25/2008
Last Update Date	:	01/13/2011

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