Provider Demographics
NPI:1063845188
Name:O'SULLIVAN, STEPHANIE GERRISH (BAPY,AT)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:GERRISH
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:BAPY,AT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:623 VILLAGE WALK
Mailing Address - Street 2:
Mailing Address - City:GUILFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06437
Mailing Address - Country:US
Mailing Address - Phone:203-779-9414
Mailing Address - Fax:
Practice Address - Street 1:623 VILLAGE WALK
Practice Address - Street 2:
Practice Address - City:GUILFORD
Practice Address - State:CT
Practice Address - Zip Code:06437
Practice Address - Country:US
Practice Address - Phone:203-779-9414
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-13
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT174H00000XMedicaid