Provider Demographics
NPI:1265089411
Name:SULLIVAN, EMILY ANNE
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ANNE
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 1:607 NORTH AVE
Mailing Address - Street 2:DOOR 11 2ND FLOOR
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880
Mailing Address - Country:US
Mailing Address - Phone:866-926-4345
Mailing Address - Fax:
Practice Address - Street 1:607 NORTH AVE
Practice Address - Street 2:DOOR 11 2ND FLOOR
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880
Practice Address - Country:US
Practice Address - Phone:866-926-4345
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst