MEDICARE: MRS. SUSAN HUBER SULLIVAN MS, 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	3532	NC

General Provider Information

NPI Number	:	1861698144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. SUSAN HUBER SULLIVAN MS, LPC

Provider Business Mailing Address
First Line	:	352 CAPE BRETON TRIL
Second Line	:
City	:	GASTONIA
State	:	NC
Zip	:	28056-8355
Country	:	US
Telephone Number	:	704-487-9325
Fax Number	:	704-487-9314

Provider Business Practice Location Address
First Line	:	407 W WARREN ST
Second Line	:
City	:	SHELBY
State	:	NC
Zip	:	28150-5329
Country	:	US
Telephone Number	:	704-487-9325
Fax Number	:	704-487-9314

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

Provider Enumeration Date	:	06/25/2007
Last Update Date	:	07/08/2007

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