Provider Demographics
NPI:1407057326
Name:SULLIVAN, MAUREEN MARY (MSW, CSW-R)
Entity Type:Individual
Prefix:MS
First Name:MAUREEN
Middle Name:MARY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSW, CSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:582 NEW LOUDON RD
Mailing Address - Street 2:
Mailing Address - City:LATHAM
Mailing Address - State:NY
Mailing Address - Zip Code:12110-4029
Mailing Address - Country:US
Mailing Address - Phone:518-783-6059
Mailing Address - Fax:518-783-4793
Practice Address - Street 1:582 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4029
Practice Address - Country:US
Practice Address - Phone:518-783-6059
Practice Address - Fax:518-783-4793
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR044185-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical