MEDICARE: BONNIE ELIZABETH SULLIVAN LCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1041C0700X	Clinical Social Worker	R058997-1	NY

General Provider Information

NPI Number	:	1144370677
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BONNIE ELIZABETH SULLIVAN LCS

Provider Business Mailing Address
First Line	:	3840 BAYS FERRY TRL
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-5287
Country	:	US
Telephone Number	:	678-560-5458
Fax Number	:	678-560-5458

Provider Business Practice Location Address
First Line	:	3840 BAYS FERRY TRL
Second Line	:
City	:	MARIETTA
State	:	GA
Zip	:	30062-5287
Country	:	US
Telephone Number	:	678-560-5458
Fax Number	:	678-560-5458

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/10/2007
Last Update Date	:	07/08/2007

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