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General NPI Number Information
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NPI Number | 1497851885
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Entity Type | Individual
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Provider Name | KATHLEEN ELLEN SULLIVAN LCSW
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Gender | Female
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Dates
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Enumeration Date | 09/15/2006
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Last Update Date | 10/20/2015
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Provider Practice Location Address
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Address Line | 16 LINCOLN ST. SUITE C
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City | BRUNSWICK
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State | ME
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Zip | 04032
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Country | US
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Telephone | 207-400-2454
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Fax |
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Provider Business Mailing Address
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Address Line | P.O. BOX 523
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City | FREEPORT
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State | ME
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Zip | 04032
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Country | US
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Telephone | 207-865-6695
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | LC469
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License Number State | ME
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Taxonomy #2
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Taxonomy Code | 1041C0700X
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Taxonomy Name | Clinical Social Worker
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License Number | #469
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License Number State | ME
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