Provider Demographics
NPI:1982885240
Name:O'SULLIVA, WALDENA ROSE (MAMFT)
Entity Type:Individual
Prefix:MRS
First Name:WALDENA
Middle Name:ROSE
Last Name:O'SULLIVA
Suffix:
Gender:F
Credentials:MAMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5776 ST. AUGUSTINE ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32207-2457
Mailing Address - Country:US
Mailing Address - Phone:904-745-3070
Mailing Address - Fax:904-745-3087
Practice Address - Street 1:5776 ST. AUGUSTINE ROAD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-2457
Practice Address - Country:US
Practice Address - Phone:904-745-3070
Practice Address - Fax:904-745-3087
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2007-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health