=====================================================
General NPI Number Information
=====================================================
NPI Number | 1154768067
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SULLIVAN MIDGE FITZGERALD LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/31/2013
-----------------------------------------------------
Last Update Date | 12/11/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 N 5TH AVE STE 230
-----------------------------------------------------
City | ANN ARBOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48104-5504
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-216-0417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 980304
-----------------------------------------------------
City | YPSILANTI
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48198-0304
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-216-0417
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | 6801095569
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------