MEDICARE: MR. BRUCE WAYNE 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
1	101YP2500X	Professional Counselor	0727	MS

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	LPC	OTHER	MS	MENTAL HEALTH

General Provider Information

NPI Number	:	1508836537
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRUCE WAYNE SULLIVAN LPC

Provider Business Mailing Address
First Line	:	450 E PASS RD
Second Line	:	STE. 3
City	:	GULFPORT
State	:	MS
Zip	:	39507-3212
Country	:	US
Telephone Number	:	228-604-0099
Fax Number	:	228-604-2001

Provider Business Practice Location Address
First Line	:	450 E PASS RD
Second Line	:	STE. 3
City	:	GULFPORT
State	:	MS
Zip	:	39507-3212
Country	:	US
Telephone Number	:	228-604-0099
Fax Number	:	228-604-2001

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

Provider Enumeration Date	:	01/24/2006
Last Update Date	:	07/08/2007

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