Provider Demographics
NPI:1144315607
Name:SULLIVAN, SUSAN ELIZABETH (PHD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:ELIZABETH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13 WELBY ROAD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:NEW BEDFORD
Mailing Address - State:MA
Mailing Address - Zip Code:02745-1132
Mailing Address - Country:US
Mailing Address - Phone:508-998-1115
Mailing Address - Fax:508-998-1140
Practice Address - Street 1:13 WELBY ROAD
Practice Address - Street 2:SUITE 2
Practice Address - City:NEW BEDFORD
Practice Address - State:MA
Practice Address - Zip Code:02745-1132
Practice Address - Country:US
Practice Address - Phone:508-998-1115
Practice Address - Fax:508-998-1140
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA2364103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAWO2805Medicare ID - Type Unspecified