Provider Demographics
NPI:1639233786
Name:SULLIVAN, PATRICIA PAULINE (LMSW LMFT DCSW)
Entity Type:Individual
Prefix:MS
First Name:PATRICIA
Middle Name:PAULINE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMSW LMFT DCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1864 E US 23
Mailing Address - Street 2:SUITE B
Mailing Address - City:EAST TAWAS
Mailing Address - State:MI
Mailing Address - Zip Code:48730-9349
Mailing Address - Country:US
Mailing Address - Phone:989-305-6280
Mailing Address - Fax:
Practice Address - Street 1:1864 E US 23
Practice Address - Street 2:SUITE B
Practice Address - City:EAST TAWAS
Practice Address - State:MI
Practice Address - Zip Code:48730-9349
Practice Address - Country:US
Practice Address - Phone:989-305-6280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2011-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010359111041C0700X
MI4101005476106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
08910440Medicare ID - Type Unspecified