Provider Demographics
NPI:1699838730
Name:KIELY SULLIVAN, JENNIFER (LICSW)
Entity Type:Individual
Prefix:MS
First Name:JENNIFER
Middle Name:
Last Name:KIELY SULLIVAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:MS
Other - First Name:JENNIFER
Other - Middle Name:HELEN
Other - Last Name:KIELY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1040 WALTHAM STREET
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:02421-8033
Mailing Address - Country:US
Mailing Address - Phone:781-862-3600
Mailing Address - Fax:781-860-7636
Practice Address - Street 1:1040 WALTHAM STREET
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MA
Practice Address - Zip Code:02421-8033
Practice Address - Country:US
Practice Address - Phone:781-862-3600
Practice Address - Fax:781-860-7636
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1114551041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1303287Medicaid
MA1004745OtherNHP
MA703136OtherTUFTS
MA1303287OtherMBHP
MAM18633OtherBCBC
MANP01332OtherBMC