| Organization Name: | SULLIVAN MENTAL HEALTH SERVICES LLC |
| NPI Number: | 1003101577 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JESSIE ELAINE SULLIVAN (OWNER/THERAPIST) |
| Mailing Address: | 660 S Woodruff Ave Idaho Falls |
| State: | ID US |
| Postal Code: | 834015299 |
| Phone Number: | 2085231558 |
| Fax Number: | 2085294788 |
| NPI Enumeration Date: | 06/13/2011 |
| NPI Last Update Date: | 11/30/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QM0855X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | ID |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Adolescent and Children Mental Health |
| Taxonomy Definition: | An entity, facility, or distinct part of a facility providing diagnostic, treatment, and prescriptive services related to mental and behavioral disorders in children and adolescents. Services may be provided to parents and family members of the patient in the form of conjoint, group, or individual therapy, and education and/or training. |