Provider Demographics
NPI:1679258149
Name:SULLIVAN, ROBERT JACKSON III (MSW, LCSWA)
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:JACKSON
Last Name:SULLIVAN
Suffix:III
Gender:M
Credentials:MSW, LCSWA
Other - Prefix:MR
Other - First Name:ROB
Other - Middle Name:J
Other - Last Name:SULLIVAN
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:MSW, LCSWA
Mailing Address - Street 1:3207 EDSEL PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28205-4352
Mailing Address - Country:US
Mailing Address - Phone:205-601-4845
Mailing Address - Fax:
Practice Address - Street 1:3506 W TYVOLA RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-7201
Practice Address - Country:US
Practice Address - Phone:205-601-4845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-21
Last Update Date:2023-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical