Provider Demographics
NPI:1760934368
Name:SULLIVAN, MARIA
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1734 JEFFERSON ST
Mailing Address - Street 2:STE. B
Mailing Address - City:NAPA
Mailing Address - State:CA
Mailing Address - Zip Code:94559-1732
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1734 JEFFERSON ST
Practice Address - Street 2:STE. B
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94559-1732
Practice Address - Country:US
Practice Address - Phone:707-227-4448
Practice Address - Fax:707-635-8215
Is Sole Proprietor?:No
Enumeration Date:2016-10-29
Last Update Date:2016-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAASW72754101YM0800X, 1041C0700X, 106E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst