Provider Demographics
NPI:1174973663
Name:SULLIVAN, PATRICIA (LSWA)
Entity type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LSWA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 CRANBERRY LN
Mailing Address - Street 2:
Mailing Address - City:SOUTH YARMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02664-1005
Mailing Address - Country:US
Mailing Address - Phone:508-398-4268
Mailing Address - Fax:
Practice Address - Street 1:889 W MAIN ST UNIT C
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:MA
Practice Address - Zip Code:02632-3067
Practice Address - Country:US
Practice Address - Phone:508-771-2101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA410168104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker