Provider Demographics
NPI:1083712228
Name:SULLIVAN, MARY (LP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1008 31ST AVE N
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55411-1329
Mailing Address - Country:US
Mailing Address - Phone:612-529-4311
Mailing Address - Fax:
Practice Address - Street 1:2550 UNIVERSITY AVE W
Practice Address - Street 2:SUITE 310N
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55114-1052
Practice Address - Country:US
Practice Address - Phone:651-379-5157
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNLP3263103G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103G00000XBehavioral Health & Social Service ProvidersClinical Neuropsychologist