Provider Demographics
NPI:1417034414
Name:SULLIVAN, ANN THERESE (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:ANN
Middle Name:THERESE
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 1:21 MAYPOLE RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-2311
Mailing Address - Country:US
Mailing Address - Phone:617-328-5710
Mailing Address - Fax:
Practice Address - Street 1:559 WILLARD ST
Practice Address - Street 2:BAYVIEW/SOUTHSHOREMENTALHEALTH
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169
Practice Address - Country:US
Practice Address - Phone:617-689-2531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA106936101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health