Provider Demographics
NPI:1245396225
Name:SULLIVAN, MARY KATHLEEN
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:KATHLEEN
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 1:1545 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94131-2017
Mailing Address - Country:US
Mailing Address - Phone:415-820-3958
Mailing Address - Fax:
Practice Address - Street 1:3265 17TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94110-1257
Practice Address - Country:US
Practice Address - Phone:415-437-3990
Practice Address - Fax:415-437-3994
Is Sole Proprietor?:No
Enumeration Date:2006-12-28
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF 46044106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist