Provider Demographics
NPI:1912521469
Name:SULLIVAN, MIRANDA ROSEMARIE (LICSW, MHP, SUDPT)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:ROSEMARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LICSW, MHP, SUDPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12245 N PARK AVE N
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98133-8026
Mailing Address - Country:US
Mailing Address - Phone:206-551-1464
Mailing Address - Fax:
Practice Address - Street 1:12245 N PARK AVE N
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98133-8026
Practice Address - Country:US
Practice Address - Phone:206-551-1464
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-01
Last Update Date:2024-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACO61062660101YA0400X
WALW615419361041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)