Provider Demographics
NPI:1457097164
Name:SOPER-SULLIVAN, CONNOR (LICSW)
Entity type:Individual
Prefix:
First Name:CONNOR
Middle Name:
Last Name:SOPER-SULLIVAN
Suffix:
Gender:
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:82 WENDELL AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01201-7066
Mailing Address - Country:US
Mailing Address - Phone:781-202-5455
Mailing Address - Fax:
Practice Address - Street 1:44 COLBORNE RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135-4103
Practice Address - Country:US
Practice Address - Phone:781-202-5455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-06
Last Update Date:2025-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA9731881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical