1255641072 NPI number — MRS. REBECHA KAY SULLIVAN LCSW

Table of content: MRS. REBECHA KAY SULLIVAN LCSW (NPI 1255641072)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255641072 NPI number — MRS. REBECHA KAY SULLIVAN LCSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SULLIVAN
Provider First Name:
REBECHA
Provider Middle Name:
KAY
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
LCSW
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
STOCKWELL
Provider Other First Name:
REBECHA
Provider Other Middle Name:
K
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:
1255641072
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/29/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
35 TIMBERLAND WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHBURY
Provider Business Mailing Address State Name:
CT
Provider Business Mailing Address Postal Code:
06488
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
203-915-7688
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
35 TIMBERLAND WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTHBURY
Provider Business Practice Location Address State Name:
CT
Provider Business Practice Location Address Postal Code:
06488
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
203-915-7688
Provider Business Practice Location Address Fax Number:
203-924-2334
Provider Enumeration Date:
10/14/2010

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:  004850 , registered in the state of CT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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