Basic Information
| Provider Information | |||||||||
| NPI: | 1295161529 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | LINDSEY | ||||||||
| MiddleName: | ANN | ||||||||
| NamePrefix: | MISS | ||||||||
| NameSuffix: | |||||||||
| Credential: | MSW,BA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 4TH FLOOR ADMINISTRATION | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035749000 | ||||||||
| FaxNumber: | 2035749006 | ||||||||
| Practice Location | |||||||||
| Address1: | 141 E MAIN ST | ||||||||
| Address2: | 3RD FLOOR HOME BASED SERVICES | ||||||||
| City: | WATERBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 067022310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2035750466 | ||||||||
| FaxNumber: | 2035751817 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/18/2013 | ||||||||
| LastUpdateDate: | 03/13/2017 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | Y | Behavioral Health & Social Service Providers | Social Worker | 1041S0200X | CT | N | Behavioral Health & Social Service Providers | Social Worker | School |
ID Information
| ID | Type | State | Issuer | Description | 013 | 01 | CT | CONNECTICUT STATE DEPT OF EDUCATION-KINDERGARTEN THRU 6TH GRADE ELEMENTARY | OTHER | 071 | 01 | CT | CONNECTICUT STATE DEPT OF EDUCATION-SCHOOL SOCIAL WORKER | OTHER |