1467497099 NPI number — VICRORIA LYNN SULLIVAN LPC

Table of content: VICRORIA LYNN SULLIVAN LPC (NPI 1467497099)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467497099 NPI number — VICRORIA LYNN SULLIVAN LPC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
VICRORIA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LPC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SULLIVAN
Provider Other First Name:
TORIE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LPC
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1467497099
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6430
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGDALE
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72766-6430
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-750-2020
Provider Business Mailing Address Fax Number:
479-524-5197

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
710 S HOLLY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SILOAM SPRINGS
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72761-3304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
479-750-2020
Provider Business Practice Location Address Fax Number:
479-524-5197
Provider Enumeration Date:
06/18/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  P0304018 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 5Y705 . This is a "BLUE SHIELD PROIVDER #" identifier , issued by the state of ( AR ) . This identifiers is of the category "OTHER".