Provider Demographics
NPI:1346614641
Name:SULLIVAN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
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 1:8703 MILFORD AVE
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20910-5030
Mailing Address - Country:US
Mailing Address - Phone:202-264-0070
Mailing Address - Fax:
Practice Address - Street 1:8703 MILFORD AVE
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20910-5030
Practice Address - Country:US
Practice Address - Phone:202-264-0070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-24
Last Update Date:2024-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCLC500794011041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical