MEDICARE: STEPHANIE MARIE SULLIVAN MS, LMFT

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	106H00000X	Marriage & Family Therapist	4101007160	MI
2	106H00000X	Marriage & Family Therapist	35002289A	IN

General Provider Information

NPI Number	:	1255828307
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STEPHANIE MARIE SULLIVAN MS, LMFT

Provider Business Mailing Address
First Line	:	4805 LYNN LN
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46383-1600
Country	:	US
Telephone Number	:	248-429-9195
Fax Number	:

Provider Business Practice Location Address
First Line	:	4805 LYNN LN
Second Line	:
City	:	VALPARAISO
State	:	IN
Zip	:	46383-1600
Country	:	US
Telephone Number	:	248-429-9195
Fax Number	:

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

Provider Enumeration Date	:	04/15/2018
Last Update Date	:	01/30/2026

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