Provider Demographics
NPI:1538121488
Name:SULLIVAN, PAULA JO (LCSW)
Entity Type:Individual
Prefix:MS
First Name:PAULA
Middle Name:JO
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:PAULA
Other - Middle Name:JO
Other - Last Name:KAUTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2200 N PONCE DE LEON BLVD
Mailing Address - Street 2:STE. 4
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32084-2600
Mailing Address - Country:US
Mailing Address - Phone:904-806-6905
Mailing Address - Fax:
Practice Address - Street 1:2200 N PONCE DE LEON BLVD
Practice Address - Street 2:STE. 4
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32084-2600
Practice Address - Country:US
Practice Address - Phone:904-806-6905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2010-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW73161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLZ089ROtherBLUE CROSS BLUE SHIELD
FLZ089ROtherBLUE CROSS BLUE SHIELD
FLZ089ROtherBLUE CROSS BLUE SHIELD