Provider Demographics
NPI:1659407674
Name:SULLIVAN, EDWARD MARK (MSW, LISW-S)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:MARK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MSW, LISW-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:497 SIOUX DR
Mailing Address - Street 2:
Mailing Address - City:WESTERVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43081-2624
Mailing Address - Country:US
Mailing Address - Phone:614-318-5289
Mailing Address - Fax:614-304-3099
Practice Address - Street 1:570 N STATE ST STE 220C
Practice Address - Street 2:
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-8086
Practice Address - Country:US
Practice Address - Phone:614-696-8400
Practice Address - Fax:614-362-9909
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2024-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHI00045771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0243763Medicaid
OHPO1698877OtherMEDICARE
OH310958725026OtherCARESOURCE MEDICAID
OH310958725OtherCHAMPUS PROVIDER#
OH310958725026OtherCARESOURCE MEDICAID