Individual
MELANIE F. SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
LMFT
Contact information
Practice address
697 N 900 E, SHELLEY, ID 83274-5208
(208) 604-6019
Mailing address
697 N 900 E, SHELLEY, ID 83274-5208
(208) 604-6019
Taxonomy
Speciality
Code
Description
License number
State
106H00000X
Marriage & Family Therapist
Primary
4156
ID
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
6105145
—
ID
Enumeration date
10/19/2006
Last updated
09/30/2010
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