Provider Demographics
NPI:1053788554
Name:SULLIVAN, EMILY MARIANNE (CLC)
Entity type:Individual
Prefix:MRS
First Name:EMILY
Middle Name:MARIANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:636 LINCOLN BLVD
Mailing Address - Street 2:
Mailing Address - City:WESTWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-3433
Mailing Address - Country:US
Mailing Address - Phone:551-404-4854
Mailing Address - Fax:
Practice Address - Street 1:636 LINCOLN BLVD
Practice Address - Street 2:
Practice Address - City:WESTWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07675-3433
Practice Address - Country:US
Practice Address - Phone:551-404-4854
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ225649174N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174N00000XOther Service ProvidersLactation Consultant, Non-RN