Provider Demographics
NPI:1366582819
Name:SULLIVAN, ANTOINETTE O (LICSW)
Entity type:Individual
Prefix:MRS
First Name:ANTOINETTE
Middle Name:O
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:ANTOINETTE
Other - Middle Name:
Other - Last Name:O'BRIEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:10 DAVOL SQ
Mailing Address - Street 2:SUITE 400
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02903-4754
Mailing Address - Country:US
Mailing Address - Phone:401-421-4000
Mailing Address - Fax:401-272-1456
Practice Address - Street 1:65 VILLAGE SQUARE DR
Practice Address - Street 2:
Practice Address - City:SOUTH KINGSTOWN
Practice Address - State:RI
Practice Address - Zip Code:02879-2292
Practice Address - Country:US
Practice Address - Phone:401-789-5924
Practice Address - Fax:401-782-1770
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2024-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIISW015161041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI26561-2OtherBLUE CROSS
RIAO27438Medicaid
RI41049-2OtherBLUE CHIP