Provider Demographics
NPI:1629324017
Name:SULLIVAN, CAROL (CASE MANAGER)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CASE MANAGER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:602 WEINRICH RD TRLR 6
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88007-4857
Mailing Address - Country:US
Mailing Address - Phone:575-339-4567
Mailing Address - Fax:
Practice Address - Street 1:602 WEINRICH RD TRLR 6
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88007-4857
Practice Address - Country:US
Practice Address - Phone:575-496-1162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-03
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMT8614111NR0400X, 172M00000X, 173C00000X, 225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No111NR0400XChiropractic ProvidersChiropractorRehabilitation
No172M00000XOther Service ProvidersMechanotherapist
No173C00000XOther Service ProvidersReflexologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM74481Medicaid