Provider Demographics
NPI:1700130267
Name:SULLIVAN, MARALISSA A (MS)
Entity type:Individual
Prefix:
First Name:MARALISSA
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9012
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46899-9012
Mailing Address - Country:US
Mailing Address - Phone:260-676-0074
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 9012
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46899-9012
Practice Address - Country:US
Practice Address - Phone:260-676-0074
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-06
Last Update Date:2025-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN39002971A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health