Provider Demographics
NPI:1477780666
Name:SULLIVAN, TOM
Entity Type:Individual
Prefix:
First Name:TOM
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:118 LONG POND RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:PLYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02360-2662
Mailing Address - Country:US
Mailing Address - Phone:508-764-5632
Mailing Address - Fax:
Practice Address - Street 1:118 LONG POND RD
Practice Address - Street 2:SUITE 104
Practice Address - City:PLYMOUTH
Practice Address - State:MA
Practice Address - Zip Code:02360-2662
Practice Address - Country:US
Practice Address - Phone:508-764-5632
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker