Provider Demographics
NPI:1952446171
Name:SULLIVAN, ANTOINETTE ROTH (EDD, LCPC, ACS)
Entity Type:Individual
Prefix:DR
First Name:ANTOINETTE
Middle Name:ROTH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:EDD, LCPC, ACS
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:9480 BANTRY RD
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-5710
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:619 GOLDSBOROUGH ST
Practice Address - Street 2:
Practice Address - City:EASTON
Practice Address - State:MD
Practice Address - Zip Code:21601-3905
Practice Address - Country:US
Practice Address - Phone:410-271-4840
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC1266101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional