Provider Demographics
NPI:1285076414
Name:NANCY A. SULLIVAN, LCSW
Entity type:Organization
Organization Name:NANCY A. SULLIVAN, LCSW
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LCSW
Authorized Official - Phone:917-751-5952
Mailing Address - Street 1:159-13 HORACE HARDING EXPRESSWAY
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11365
Mailing Address - Country:US
Mailing Address - Phone:917-751-5952
Mailing Address - Fax:718-460-5488
Practice Address - Street 1:159-13 HORACE HARDING EXPRESSWAY
Practice Address - Street 2:
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11365
Practice Address - Country:US
Practice Address - Phone:917-751-5952
Practice Address - Fax:718-460-5488
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-30
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY075477251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244019Medicaid