Provider Demographics
NPI:1164942983
Name:SULLIVAN, ANDREW JAMES
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:JAMES
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:234 COPELAND ST STE 320
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-4082
Mailing Address - Country:US
Mailing Address - Phone:617-479-4545
Mailing Address - Fax:781-803-2712
Practice Address - Street 1:234 COPELAND ST STE 320
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-4082
Practice Address - Country:US
Practice Address - Phone:617-479-4545
Practice Address - Fax:617-479-4555
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X, 101YM0800X
MA1254051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health