MEDICARE: RICHARD JAMES SULLIVAN LCSW

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
1	171W00000X	Contractor	LCSW 8498	FL

General Provider Information

NPI Number	:	1841325461
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RICHARD JAMES SULLIVAN LCSW

Provider Business Mailing Address
First Line	:	2155 NE 187TH ST
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-4311
Country	:	US
Telephone Number	:	305-792-6113
Fax Number	:

Provider Business Practice Location Address
First Line	:	2155 NE 187TH ST
Second Line	:
City	:	NORTH MIAMI BEACH
State	:	FL
Zip	:	33179-4311
Country	:	US
Telephone Number	:	305-792-6113
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	07/08/2007

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