Provider Demographics
NPI:1821811704
Name:SULLIVAN, SHANNON (LCSW)
Entity type:Individual
Prefix:MS
First Name:SHANNON
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 DAY MILL DR
Mailing Address - Street 2:
Mailing Address - City:TEMPLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01468-1472
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:928 BROADWAY STE 300
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10010-8158
Practice Address - Country:US
Practice Address - Phone:833-775-6252
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-07
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALCSW2306511041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical