Provider Demographics
NPI:1336357987
Name:SULLIVAN, MARY GARDNER (LICSW)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:GARDNER
Last Name:SULLIVAN
Suffix:
Gender:F
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:PO BOX 295
Mailing Address - Street 2:
Mailing Address - City:YARMOUTH PORT
Mailing Address - State:MA
Mailing Address - Zip Code:02675-0295
Mailing Address - Country:US
Mailing Address - Phone:508-362-7167
Mailing Address - Fax:
Practice Address - Street 1:923 ROUTE 6A
Practice Address - Street 2:SUITE T
Practice Address - City:YARMOUTH PORT
Practice Address - State:MA
Practice Address - Zip Code:02675-2159
Practice Address - Country:US
Practice Address - Phone:508-654-0905
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-18
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1141611041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP30025Medicare ID - Type Unspecified