Provider Demographics
NPI:1497960603
Name:SULLIVAN, DIANNE BERNADETTE (MED LMFT)
Entity Type:Individual
Prefix:MRS
First Name:DIANNE
Middle Name:BERNADETTE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MED LMFT
Other - Prefix:
Other - First Name:DIANNE
Other - Middle Name:CELIA
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:714 PROSPECT AVENUE
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06105
Mailing Address - Country:US
Mailing Address - Phone:860-586-8800
Mailing Address - Fax:860-570-0886
Practice Address - Street 1:714 PROSPECT AVENUE
Practice Address - Street 2:
Practice Address - City:HARFORD
Practice Address - State:CT
Practice Address - Zip Code:06105
Practice Address - Country:US
Practice Address - Phone:860-586-8800
Practice Address - Fax:860-570-0886
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000497106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist