Provider Demographics
NPI:1982301271
Name:SULLIVAN, NICOLE M (LMFT)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:
Other - Last Name:MASTRACCHIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LMFT
Mailing Address - Street 1:510 WALNUT ST STE 1425
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19106-3622
Mailing Address - Country:US
Mailing Address - Phone:610-892-3800
Mailing Address - Fax:484-468-1412
Practice Address - Street 1:510 WALNUT ST STE 1425
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19106-3622
Practice Address - Country:US
Practice Address - Phone:610-892-3800
Practice Address - Fax:484-468-1412
Is Sole Proprietor?:No
Enumeration Date:2023-02-08
Last Update Date:2025-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMF001484106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist