Provider Demographics
NPI:1548224355
Name:SULLIVAN, ROBERT ALLEN (LICSW)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:ALLEN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1930 COON RAPIDS BLVD
Mailing Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433
Mailing Address - Country:US
Mailing Address - Phone:763-746-9583
Mailing Address - Fax:763-746-9597
Practice Address - Street 1:1930 COON RAPIDS BLVD
Practice Address - Street 2:FAMILY LIFE MENTAL HEALTH CENTER
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433
Practice Address - Country:US
Practice Address - Phone:763-427-7964
Practice Address - Fax:763-427-7976
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN81041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
HP17514OtherHEALTH PARTNERS
6200879OtherUBH
106772OtherUCARE
MN32A98SUOtherBCBS
MN1023456OtherPREFERRED ONE