Healthcare Provider Details

I. General information

NPI: 1407580996
Provider Name (Legal Business Name): BRIDGET K SULLIVAN LPMA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2022
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

174 HOSPITAL LOOP
BERLIN VT
05602-9105
US

IV. Provider business mailing address

174 HOSPITAL LOOP
BERLIN VT
05602-9105
US

V. Phone/Fax

Practice location:
  • Phone: 802-479-4083
  • Fax: 802-476-1476
Mailing address:
  • Phone: 802-479-4083
  • Fax: 802-476-1476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number047.0133698
License Number StateVT
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: