MEDICARE: BRANDI SULLIVAN LCSW

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	SW19390	FL

General Provider Information

NPI Number	:	1235885682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDI SULLIVAN LCSW

Provider Business Mailing Address
First Line	:	4440 FORT SHAW DR
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34655-7314
Country	:	US
Telephone Number	:	813-751-4804
Fax Number	:

Provider Business Practice Location Address
First Line	:	4440 FORT SHAW DR
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34655-7314
Country	:	US
Telephone Number	:	813-751-4804
Fax Number	:

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

Provider Enumeration Date	:	02/24/2022
Last Update Date	:	09/03/2024

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