Provider Demographics
NPI:1174551030
Name:SULLIVAN, MARY M (LCSW)
Entity type:Individual
Prefix:MS
First Name:MARY
Middle Name:M
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 1:132 E PUTNAM AVE
Mailing Address - Street 2:
Mailing Address - City:COS COB
Mailing Address - State:CT
Mailing Address - Zip Code:06807-2744
Mailing Address - Country:US
Mailing Address - Phone:203-962-2209
Mailing Address - Fax:203-962-2209
Practice Address - Street 1:132 E PUTNAM AVE
Practice Address - Street 2:SUITE H
Practice Address - City:COS COB
Practice Address - State:CT
Practice Address - Zip Code:06807-2744
Practice Address - Country:US
Practice Address - Phone:203-962-2209
Practice Address - Fax:203-962-2209
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-29
Last Update Date:2011-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0058141041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004172920Medicaid
CT004172912Medicaid