1801083514 NPI number — MRS. MARY LOU SULLIVAN MA COUNSELING MFCC

Table of content: MRS. MARY LOU SULLIVAN MA COUNSELING MFCC (NPI 1801083514)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1801083514 NPI number — MRS. MARY LOU SULLIVAN MA COUNSELING MFCC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
MARY
Provider Middle Name:
LOU
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MA COUNSELING MFCC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BACCI VILLAVICENCIO
Provider Other First Name:
MARY
Provider Other Middle Name:
LOU
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1801083514
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/26/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1132 SW 13TH AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97205-1703
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-535-3885
Provider Business Mailing Address Fax Number:
503-223-6837

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1132 SW 13TH AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97205-1703
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-535-3885
Provider Business Practice Location Address Fax Number:
503-223-6837
Provider Enumeration Date:
09/26/2007

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: 101YM0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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