Provider Demographics
NPI:1730947599
Name:SULLIVAN, THEODORE (LMHCA)
Entity type:Individual
Prefix:
First Name:THEODORE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LMHCA
Other - Prefix:
Other - First Name:TEDDY
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LMCHA
Mailing Address - Street 1:1487 N BRUMMITT RD
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2501 VALLEY DR
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2518
Practice Address - Country:US
Practice Address - Phone:219-323-3311
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-07
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN88002140A101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health