Provider Demographics
NPI:1184787194
Name:SULLIVAN, PENNY A (MSW)
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:PENNY
Other - Middle Name:A
Other - Last Name:BROOKS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:32 MILTON ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-3339
Mailing Address - Country:US
Mailing Address - Phone:508-588-7649
Mailing Address - Fax:
Practice Address - Street 1:1353 DORCHESTER AVE
Practice Address - Street 2:
Practice Address - City:DORCHESTER
Practice Address - State:MA
Practice Address - Zip Code:02122-2932
Practice Address - Country:US
Practice Address - Phone:617-288-3230
Practice Address - Fax:617-825-4972
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health