Provider Demographics
NPI:1609961630
Name:SULLIVAN, MARY E (LCSW)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:102 MAIN ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:HIGHTSTOWN
Mailing Address - State:NJ
Mailing Address - Zip Code:08520-4800
Mailing Address - Country:US
Mailing Address - Phone:609-443-3970
Mailing Address - Fax:609-443-8029
Practice Address - Street 1:102 MAIN ST
Practice Address - Street 2:SUITE 1
Practice Address - City:HIGHTSTOWN
Practice Address - State:NJ
Practice Address - Zip Code:08520-4800
Practice Address - Country:US
Practice Address - Phone:609-443-3970
Practice Address - Fax:609-443-8029
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2014-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SC043261001041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
167870OtherMHN
6276254OtherUNITED BEH HEALTH
P809023OtherOXFORD
11626OtherVALUE OPTIONS
138555000OtherMAGELLAN
6276254OtherUNITED BEH HEALTH