Provider Demographics
NPI:1063532372
Name:SULLIVAN, SHARLENE MARY (MA LDAC1)
Entity type:Individual
Prefix:
First Name:SHARLENE
Middle Name:MARY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA LDAC1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 MYRON ST STE A
Mailing Address - Street 2:
Mailing Address - City:WEST SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01089-1485
Mailing Address - Country:US
Mailing Address - Phone:413-592-1980
Mailing Address - Fax:413-439-0100
Practice Address - Street 1:103 MYRON ST STE A
Practice Address - Street 2:
Practice Address - City:WEST SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01089
Practice Address - Country:US
Practice Address - Phone:413-592-1980
Practice Address - Fax:413-439-0100
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-30
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA789101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)