Healthcare Provider Details

I. General information

NPI: 1194825331
Provider Name (Legal Business Name): JOHN JOSEPH SULLIVAN MSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

114 BOSTON POST RD
WEST HAVEN CT
06516-2043
US

IV. Provider business mailing address

466 CHIPMAN STREET EXT
WATERBURY CT
06708-3638
US

V. Phone/Fax

Practice location:
  • Phone: 203-931-4032
  • Fax: 203-931-4068
Mailing address:
  • Phone: 203-575-1155
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: