MEDICARE: SULLIVAN COUNSELING

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	1041C0700X	Clinical Social Worker	34001106A	IN

General Provider Information

NPI Number	:	1487903159
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SULLIVAN COUNSELING

Provider Business Mailing Address
First Line	:	10311 DAWSONS CREEK BLVD STE E
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1913
Country	:	US
Telephone Number	:	260-451-2500
Fax Number	:	260-451-2501

Provider Business Practice Location Address
First Line	:	10311 DAWSONS CREEK BLVD STE E
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46825-1913
Country	:	US
Telephone Number	:	260-451-2500
Fax Number	:	260-451-2501

Authorized Official
Title or Position	:	OWNER
Name	:	DIAN K SULLIVAN
Credential	:	LCSW
Telephone Number	:	260-451-2500

Provider Enumeration Date	:	09/10/2012
Last Update Date	:	03/13/2015

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