Provider Demographics
NPI:1902272651
Name:SULLIVAN, MARIA (LCSW)
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
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 3546
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19122-0546
Mailing Address - Country:US
Mailing Address - Phone:215-486-0858
Mailing Address - Fax:207-531-3582
Practice Address - Street 1:1299 N 7TH ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19122-4396
Practice Address - Country:US
Practice Address - Phone:215-486-0858
Practice Address - Fax:207-531-3582
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-17
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1041C0700X
PACW0214201041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1144329111Medicaid