Provider Demographics
NPI:1487459160
Name:SULLIVAN, MICHAELLE
Entity type:Individual
Prefix:
First Name:MICHAELLE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 ELM ST APT 1
Mailing Address - Street 2:
Mailing Address - City:MONTCLAIR
Mailing Address - State:NJ
Mailing Address - Zip Code:07042-3265
Mailing Address - Country:US
Mailing Address - Phone:862-285-1869
Mailing Address - Fax:
Practice Address - Street 1:622-624 VALLEY RD
Practice Address - Street 2:
Practice Address - City:UPPER MONTCLAIR
Practice Address - State:NJ
Practice Address - Zip Code:07043-1462
Practice Address - Country:US
Practice Address - Phone:732-674-9857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-17
Last Update Date:2025-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00855800101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor