Provider Demographics
NPI:1588994479
Name:SULLIVAN, ELLEN WATTERS (LICSW)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:WATTERS
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 372
Mailing Address - Street 2:
Mailing Address - City:NORTH EASTHAM
Mailing Address - State:MA
Mailing Address - Zip Code:02651-0372
Mailing Address - Country:US
Mailing Address - Phone:339-221-4511
Mailing Address - Fax:
Practice Address - Street 1:125 SEAWARD WAY
Practice Address - Street 2:
Practice Address - City:EASTHAM
Practice Address - State:MA
Practice Address - Zip Code:02642
Practice Address - Country:US
Practice Address - Phone:339-221-4511
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-28
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1175061041C0700X
VT089.00617241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical