1154768067 NPI number — SULLIVAN MIDGE FITZGERALD LMSW

Table of content: CHRISTIAN DRUMMOND (NPI 1104497098)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154768067 NPI number — SULLIVAN MIDGE FITZGERALD LMSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FITZGERALD
Provider First Name:
SULLIVAN
Provider Middle Name:
MIDGE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
LMSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
FITZGERALD
Provider Other First Name:
SARA
Provider Other Middle Name:
MAUREEN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
LMSW
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1154768067
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/11/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 980304
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YPSILANTI
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48198-0304
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
734-216-0417
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
300 N 5TH AVE STE 230
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ANN ARBOR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48104-5504
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
734-216-0417
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/31/2013

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1041C0700X , with the licence number:  6801095569 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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