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NPI Code Detail

MEDICARE: VICRORIA LYNN SULLIVAN LPC

MEDICARE: VICRORIA LYNN SULLIVAN LPC
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
1101YP2500XProfessional CounselorP0304018AR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
15Y705OTHERARBLUE SHIELD PROIVDER #

General Provider Information

NPI Number : 1467497099
Entity Type Code : Individual
Provider Name (Legal Business Name) : VICRORIA LYNN SULLIVAN LPC
Provider Business Mailing Address
First Line : PO BOX 6430
Second Line :
City : SPRINGDALE
State : AR
Zip : 72766-6430
Country : US
Telephone Number : 479-750-2020
Fax Number : 479-524-5197
Provider Business Practice Location Address
First Line : 710 S HOLLY ST
Second Line :
City : SILOAM SPRINGS
State : AR
Zip : 72761-3304
Country : US
Telephone Number : 479-750-2020
Fax Number : 479-524-5197
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/18/2006
Last Update Date : 07/08/2007

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