1366582819 NPI number — MRS. ANTOINETTE O SULLIVAN LICSW

Table of content: MRS. ANTOINETTE O SULLIVAN LICSW (NPI 1366582819)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366582819 NPI number — MRS. ANTOINETTE O SULLIVAN LICSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
ANTOINETTE
Provider Middle Name:
O
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LICSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
O'BRIEN
Provider Other First Name:
ANTOINETTE
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1366582819
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10 DAVOL SQ
Provider Second Line Business Mailing Address:
SUITE 400
Provider Business Mailing Address City Name:
PROVIDENCE
Provider Business Mailing Address State Name:
RI
Provider Business Mailing Address Postal Code:
02903-4754
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
401-421-4000
Provider Business Mailing Address Fax Number:
401-272-1456

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
65 VILLAGE SQUARE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH KINGSTOWN
Provider Business Practice Location Address State Name:
RI
Provider Business Practice Location Address Postal Code:
02879-2292
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
401-789-5924
Provider Business Practice Location Address Fax Number:
401-782-1770
Provider Enumeration Date:
02/07/2007

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:  ISW01516 , registered in the state of RI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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