Provider Demographics
NPI:1881622306
Name:SULLIVAN, SUSAN BRIDGET (LCSW)
Entity type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:BRIDGET
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 1:1013 OAK DR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-6265
Mailing Address - Country:US
Mailing Address - Phone:252-422-1655
Mailing Address - Fax:
Practice Address - Street 1:400 COMMERCE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-3421
Practice Address - Country:US
Practice Address - Phone:252-422-1655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCC0040861041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6106063Medicaid
NC1400AOtherBLUE CROSS
NC6106063Medicaid