Provider Demographics
NPI:1578985479
Name:SULLIVAN, RICHARD A (BA, LSW)
Entity Type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:BA, LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26 VIDEN RD
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-7907
Mailing Address - Country:US
Mailing Address - Phone:857-488-5373
Mailing Address - Fax:617-516-0281
Practice Address - Street 1:26 VIDEN RD
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-7907
Practice Address - Country:US
Practice Address - Phone:857-488-5373
Practice Address - Fax:617-516-0281
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-10
Last Update Date:2016-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101Y00000X
MA314564104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101Y00000XBehavioral Health & Social Service ProvidersCounselor