MEDICARE: ANNA VICTORIA SULLIVAN

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	101YA0400X	Addiction (Substance Use Disorder) Counselor	25-01-20524	OR
2	101YM0800X	Mental Health Counselor	24-QMHPC-001530	OR

General Provider Information

NPI Number	:	1598416471
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNA VICTORIA SULLIVAN

Provider Business Mailing Address
First Line	:	1305 SE 87TH AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97216-1801
Country	:	US
Telephone Number	:	509-212-8256
Fax Number	:

Provider Business Practice Location Address
First Line	:	4943 NE MARTIN LUTHER KING JR BLVD
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97211-3511
Country	:	US
Telephone Number	:	971-292-1960
Fax Number	:

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

Provider Enumeration Date	:	01/12/2022
Last Update Date	:	06/05/2026

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Directions to “ ANNA VICTORIA SULLIVAN ” Practice Location

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