Provider Demographics
NPI:1457097164
Name:SULLIVAN, CONNOR (LCSW)
Entity Type:Individual
Prefix:
First Name:CONNOR
Middle Name:
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 1:77 WARREN ST BLDG 2
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-3601
Mailing Address - Country:US
Mailing Address - Phone:617-783-7804
Mailing Address - Fax:
Practice Address - Street 1:77 WARREN ST BLDG 2
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-3601
Practice Address - Country:US
Practice Address - Phone:617-783-7804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2022-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9731881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical