Provider Demographics
NPI:1316930282
Name:SULLIVAN, NANCY JANE (LCSW, MSW, MED)
Entity type:Individual
Prefix:MS
First Name:NANCY
Middle Name:JANE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW, MSW, MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1718 8TH AVE SW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-5216
Mailing Address - Country:US
Mailing Address - Phone:360-754-9330
Mailing Address - Fax:
Practice Address - Street 1:1800 COOPER POINT RD SW
Practice Address - Street 2:BUILDING 24B
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-1178
Practice Address - Country:US
Practice Address - Phone:360-786-1195
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALW000041501041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1263101000OtherUNIFORM MEDICAL PLAN
KY0007652345OtherAETNA
WA1263101000OtherUNIFORM MEDICAL PLAN