Provider Demographics
NPI:1275968927
Name:SULLIVAN, DEBORAH MAE
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:MAE
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 1:190 MOSSY OAK CIR
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29841-3093
Mailing Address - Country:US
Mailing Address - Phone:706-627-6219
Mailing Address - Fax:803-341-9761
Practice Address - Street 1:190 MOSSY OAK CIR
Practice Address - Street 2:
Practice Address - City:NORTH AUGUSTA
Practice Address - State:SC
Practice Address - Zip Code:29841-3093
Practice Address - Country:US
Practice Address - Phone:706-627-6219
Practice Address - Fax:803-341-9761
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-12
Last Update Date:2014-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator