Provider Demographics
NPI:1164651675
Name:SULLIVAN, MARY B
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:B
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 314
Mailing Address - Street 2:
Mailing Address - City:TORRINGTON
Mailing Address - State:WY
Mailing Address - Zip Code:82240-0314
Mailing Address - Country:US
Mailing Address - Phone:307-532-6296
Mailing Address - Fax:307-532-8519
Practice Address - Street 1:1138 W C ST
Practice Address - Street 2:
Practice Address - City:TORRINGTON
Practice Address - State:WY
Practice Address - Zip Code:82240-3371
Practice Address - Country:US
Practice Address - Phone:307-532-6296
Practice Address - Fax:307-532-8519
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator