Provider Demographics
NPI:1609392737
Name:SULLIVAN, SHANNON MARIE
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:859 WILLARD ST STE 430
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-7490
Mailing Address - Country:US
Mailing Address - Phone:617-847-1950
Mailing Address - Fax:617-774-1490
Practice Address - Street 1:859 WILLARD ST STE 430
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-7490
Practice Address - Country:US
Practice Address - Phone:617-847-1950
Practice Address - Fax:617-774-1490
Is Sole Proprietor?:No
Enumeration Date:2017-08-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health