Provider Demographics
NPI:1427175249
Name:SULLIVAN, MAURA CORCORAN (PSYD)
Entity type:Individual
Prefix:DR
First Name:MAURA
Middle Name:CORCORAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 MIDDLE ST
Mailing Address - Street 2:SUITE 300
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4075
Mailing Address - Country:US
Mailing Address - Phone:207-871-0447
Mailing Address - Fax:207-772-2670
Practice Address - Street 1:178 MIDDLE ST
Practice Address - Street 2:SUITE 300
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4075
Practice Address - Country:US
Practice Address - Phone:207-871-0447
Practice Address - Fax:207-772-2670
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPS837103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEMM5981Medicare ID - Type Unspecified