Provider Demographics
NPI:1174992788
Name:SULLIVAN, MARTINA M (MSW)
Entity type:Individual
Prefix:
First Name:MARTINA
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:190 STETSON RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-7813
Mailing Address - Country:US
Mailing Address - Phone:207-784-7388
Mailing Address - Fax:207-795-2043
Practice Address - Street 1:190 STETSON RD
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-7813
Practice Address - Country:US
Practice Address - Phone:207-784-7388
Practice Address - Fax:207-795-2043
Is Sole Proprietor?:No
Enumeration Date:2015-09-24
Last Update Date:2015-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC12471104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker