Provider Demographics
NPI:1831297670
Name:SULLIVAN, JAMES M (LICSW #114273)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LICSW #114273
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 OCEAN HILL DR
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02334
Mailing Address - Country:US
Mailing Address - Phone:617-910-6078
Mailing Address - Fax:617-275-8772
Practice Address - Street 1:28 OCEAN HILL DR
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:MA
Practice Address - Zip Code:02334
Practice Address - Country:US
Practice Address - Phone:617-910-6078
Practice Address - Fax:617-275-8772
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA213178104100000X
MA114273101YA0400X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health