Provider Demographics
NPI:1154484087
Name:SULLIVAN, MARJORIE B (LICSW MSS)
Entity Type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:B
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LICSW MSS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:47 ALGELO AVE
Mailing Address - Street 2:
Mailing Address - City:WAREHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02571
Mailing Address - Country:US
Mailing Address - Phone:508-291-0729
Mailing Address - Fax:
Practice Address - Street 1:1342 BELMONT STREET
Practice Address - Street 2:SUITE 101 VAN S BATCHIS MD AND ASSOC
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301
Practice Address - Country:US
Practice Address - Phone:508-588-1290
Practice Address - Fax:508-588-4639
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10175161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P05115Medicare ID - Type Unspecified