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NPI Code Detail

MEDICARE: SUSAN SULLIVAN L.I.C.S.W.

MEDICARE: SUSAN SULLIVAN L.I.C.S.W.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
11041C0700XClinical Social Worker216664MA

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number : 1417258302
Entity Type Code : Individual
Provider Name (Legal Business Name) : SUSAN SULLIVAN L.I.C.S.W.
Provider Business Mailing Address
First Line : 96 SOUTH ST
Second Line :
City : WARE
State : MA
Zip : 01082-1616
Country : US
Telephone Number : 413-967-6241
Fax Number :
Provider Business Practice Location Address
First Line : 59 INTERSTATE DR STE 10
Second Line :
City : WEST SPRINGFIELD
State : MA
Zip : 01089-5100
Country : US
Telephone Number : 774-206-1125
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 11/08/2010
Last Update Date : 12/18/2022

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