Provider Demographics
NPI:1831263847
Name:SULLIVAN, PATRICIA SULLIVAN JANE (LICSW)
Entity type:Individual
Prefix:
First Name:PATRICIA SULLIVAN
Middle Name:JANE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:456 ROCK ST
Mailing Address - Street 2:
Mailing Address - City:FALL RIVER
Mailing Address - State:MA
Mailing Address - Zip Code:02720-3343
Mailing Address - Country:US
Mailing Address - Phone:508-789-1194
Mailing Address - Fax:508-672-0450
Practice Address - Street 1:456 ROCK ST
Practice Address - Street 2:
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02720-3343
Practice Address - Country:US
Practice Address - Phone:508-789-1194
Practice Address - Fax:508-672-0450
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2013-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA975101YA0400X
MA10258881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA1859218Medicaid
MAP22492Medicare ID - Type Unspecified