MEDICARE: GARY HODGES 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	LPC008887	GA
2	101YM0800X	Mental Health Counselor	LPC008887	GA

General Provider Information

NPI Number	:	1790231207
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GARY HODGES SULLIVAN LPC

Provider Business Mailing Address
First Line	:	165 BLUE RIDGE OVERLOOK
Second Line	:
City	:	BLUE RIDGE
State	:	GA
Zip	:	30513-4431
Country	:	US
Telephone Number	:	706-946-5607
Fax Number	:	706-374-7628

Provider Business Practice Location Address
First Line	:	153 SCHOOL DR
Second Line	:
City	:	DAHLONEGA
State	:	GA
Zip	:	30533-0313
Country	:	US
Telephone Number	:	706-973-3215
Fax Number	:	706-973-3216

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

Provider Enumeration Date	:	08/26/2016
Last Update Date	:	11/09/2023

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