Provider Demographics
NPI:1497851885
Name:SULLIVAN, KATHLEEN ELLEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:ELLEN
Last Name:SULLIVAN
Suffix:
Gender:F
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:P.O. BOX 523
Mailing Address - Street 2:
Mailing Address - City:FREEPORT
Mailing Address - State:ME
Mailing Address - Zip Code:04032
Mailing Address - Country:US
Mailing Address - Phone:207-865-6695
Mailing Address - Fax:
Practice Address - Street 1:16 LINCOLN ST.
Practice Address - Street 2:SUITE C
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04032
Practice Address - Country:US
Practice Address - Phone:207-400-2454
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-15
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC4691041C0700X
ME#4691041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM581001Medicare UPIN
ME005691Medicare UPIN
MEMM5810Medicare ID - Type UnspecifiedMEDICARE NUMBER