Healthcare Provider Details

I. General information

NPI: 1265313712
Provider Name (Legal Business Name): CARRIE SULLIVAN MT-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/10/2025
Last Update Date: 10/24/2025
Certification Date: 09/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 LEXINGTON ST
BELMONT MA
02478-1240
US

IV. Provider business mailing address

5 ROSE LN
BERKLEY MA
02779-1014
US

V. Phone/Fax

Practice location:
  • Phone: 774-504-8550
  • Fax:
Mailing address:
  • Phone: 774-504-8550
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225A00000X
TaxonomyMusic Therapist
License Number19669
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: