Provider Demographics
NPI:1639110273
Name:SULLIVAN, MAURA D (PSYD)
Entity Type:Individual
Prefix:DR
First Name:MAURA
Middle Name:D
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3583 NE BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-1820
Mailing Address - Country:US
Mailing Address - Phone:503-432-8470
Mailing Address - Fax:503-912-7018
Practice Address - Street 1:3583 NE BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-1820
Practice Address - Country:US
Practice Address - Phone:503-432-8470
Practice Address - Fax:503-912-7018
Is Sole Proprietor?:No
Enumeration Date:2006-06-08
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH1012103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30425095Medicaid
NHRE7355Medicare PIN