MEDICARE: MICHELLE P SULLIVAN LCSW

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	104100000X	Social Worker	CW014390	PA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	SU 763420	OTHER	PA	HIGHMARK

General Provider Information

NPI Number	:	1134110760
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE P SULLIVAN LCSW

Provider Business Mailing Address
First Line	:	4700 LAS VEGAS BLVD N
Second Line	:	MIKE O'CALLAGHAN FEDERAL MEDICAL CENTER
City	:	NELLIS AFB
State	:	NV
Zip	:	89191-6600
Country	:	US
Telephone Number	:	702-653-3455
Fax Number	:	702-653-3398

Provider Business Practice Location Address
First Line	:	4700 NORTH LAS VEGAS BOULEVARD
Second Line	:	MIKE O'CALLAGHAN FEDERAL MEDICAL CENTER
City	:	NELLIS AIR FORCE BASE
State	:	NV
Zip	:	89191-6601
Country	:	US
Telephone Number	:	702-653-3455
Fax Number	:	702-653-3398

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

Provider Enumeration Date	:	11/02/2005
Last Update Date	:	03/10/2014

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