Provider Demographics
NPI:1740761931
Name:SULLIVAN, LAURIE (LICSW)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:LAURIE
Other - Middle Name:
Other - Last Name:MCKEAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 INDUSTRY AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01104-3349
Mailing Address - Country:US
Mailing Address - Phone:413-205-0501
Mailing Address - Fax:
Practice Address - Street 1:112 INDUSTRY AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-3349
Practice Address - Country:US
Practice Address - Phone:413-205-0501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-24
Last Update Date:2018-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1030508104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker