Provider Demographics
NPI:1003038753
Name:SULLIVAN, TIM D (MSW, LCSW)
Entity Type:Individual
Prefix:MR
First Name:TIM
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MSW, LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:229 RIDGEWOOD AVE
Mailing Address - Street 2:APARTMENT 112
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55403-3554
Mailing Address - Country:US
Mailing Address - Phone:612-600-7169
Mailing Address - Fax:
Practice Address - Street 1:229 RIDGEWOOD AVE
Practice Address - Street 2:APARTMENT 112
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55403-3554
Practice Address - Country:US
Practice Address - Phone:612-600-7169
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOSW 0035531041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical