Provider Demographics
NPI:1396840054
Name:SULLIVAN, CHRISTINE LOUISE (LICSW)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LOUISE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:CHRISTINE
Other - Middle Name:LOUISE
Other - Last Name:DRECHSLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW LICSW
Mailing Address - Street 1:1968 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEEDHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02492-1410
Mailing Address - Country:US
Mailing Address - Phone:781-292-2136
Mailing Address - Fax:
Practice Address - Street 1:1968 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:NEEDHAM
Practice Address - State:MA
Practice Address - Zip Code:02492-1410
Practice Address - Country:US
Practice Address - Phone:781-292-2136
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA111835104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1200925Medicaid