Provider Demographics
NPI:1356818710
Name:SULLIVAN, MEREDITH (LICSW)
Entity Type:Individual
Prefix:
First Name:MEREDITH
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1507 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02465-2219
Mailing Address - Country:US
Mailing Address - Phone:617-965-0764
Mailing Address - Fax:
Practice Address - Street 1:1507 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02465-2219
Practice Address - Country:US
Practice Address - Phone:617-965-0764
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA115010101YS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool