Provider Demographics
NPI:1912521469
Name:SULLIVAN, MIRANDA ROSEMARIE
Entity Type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ROSEMARIE
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 1:2400 NE 95TH ST
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98115-2426
Mailing Address - Country:US
Mailing Address - Phone:206-418-8831
Mailing Address - Fax:
Practice Address - Street 1:2400 NE 95TH ST
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98115-2426
Practice Address - Country:US
Practice Address - Phone:206-418-8831
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker