Provider Demographics
NPI:1306904750
Name:SULLIVAN, LAURA M (LCSW)
Entity type:Individual
Prefix:MS
First Name:LAURA
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14014 ROUTE 31
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:NY
Mailing Address - Zip Code:14411-1498
Mailing Address - Country:US
Mailing Address - Phone:585-589-7066
Mailing Address - Fax:585-589-6395
Practice Address - Street 1:14014 STATE ROUTE 31
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:NY
Practice Address - Zip Code:14411-9301
Practice Address - Country:US
Practice Address - Phone:585-589-7066
Practice Address - Fax:585-589-6395
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY072927-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00072927Medicaid
NYDD6752Medicare ID - Type Unspecified
NY00072927Medicaid