Provider Demographics
NPI:1154478741
Name:SULLIVAN, JOHN GERARD (LICSW)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:GERARD
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LICSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:160 KELLOGG BLVD E
Mailing Address - Street 2:
Mailing Address - City:SAINT PAUL
Mailing Address - State:MN
Mailing Address - Zip Code:55101-1420
Mailing Address - Country:US
Mailing Address - Phone:651-266-4302
Mailing Address - Fax:651-266-4443
Practice Address - Street 1:160 KELLOGG BLVD E
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55101-1420
Practice Address - Country:US
Practice Address - Phone:651-266-4302
Practice Address - Fax:651-266-4443
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN058061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical