Healthcare Provider Details

I. General information

NPI: 1639233786
Provider Name (Legal Business Name): PATRICIA PAULINE SULLIVAN LMSW LMFT DCSW
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 10/24/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1864 E US 23 SUITE B
EAST TAWAS MI
48730-9349
US

IV. Provider business mailing address

1864 E US 23 SUITE B
EAST TAWAS MI
48730-9349
US

V. Phone/Fax

Practice location:
  • Phone: 989-305-6280
  • Fax:
Mailing address:
  • Phone: 989-305-6280
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801035911
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number4101005476
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: