Provider Demographics
NPI:1730051558
Name:SULLIVAN, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:MA
Mailing Address - Zip Code:01050-9766
Mailing Address - Country:US
Mailing Address - Phone:413-552-8420
Mailing Address - Fax:
Practice Address - Street 1:130 SOUTHAMPTON RD
Practice Address - Street 2:
Practice Address - City:WESTFIELD
Practice Address - State:MA
Practice Address - Zip Code:01085-1370
Practice Address - Country:US
Practice Address - Phone:413-485-1305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-22
Last Update Date:2025-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)