Healthcare Provider Details

I. General information

NPI: 1013804061
Provider Name (Legal Business Name): LIAM SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/23/2025
Last Update Date: 10/07/2026
Certification Date: 10/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

61 INNERBELT RD
SOMERVILLE MA
02143-4416
US

IV. Provider business mailing address

61 INNERBELT RD
SOMERVILLE MA
02143-4416
US

V. Phone/Fax

Practice location:
  • Phone: 617-863-5400
  • Fax:
Mailing address:
  • Phone: 617-863-5400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License NumberLCSW2143829
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: