Provider Demographics
NPI:1356456297
Name:SULLIVAN, MARK TIGHE (LCSW)
Entity Type:Individual
Prefix:MR
First Name:MARK
Middle Name:TIGHE
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 LIBERTY ST
Mailing Address - Street 2:
Mailing Address - City:LONG BRANCH
Mailing Address - State:NJ
Mailing Address - Zip Code:07740-7339
Mailing Address - Country:US
Mailing Address - Phone:732-869-2781
Mailing Address - Fax:
Practice Address - Street 1:1011 BOND ST
Practice Address - Street 2:
Practice Address - City:ASBURY PARK
Practice Address - State:NJ
Practice Address - Zip Code:07712-5939
Practice Address - Country:US
Practice Address - Phone:732-869-2781
Practice Address - Fax:732-897-9541
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC014704001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical