Provider Demographics
NPI:1427177484
Name:SULLIVAN, MELBA J (PHD)
Entity type:Individual
Prefix:
First Name:MELBA
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MELBA
Other - Middle Name:JENINE
Other - Last Name:NICHOLSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PHD
Mailing Address - Street 1:936 BROADWAY FL 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10010-8104
Mailing Address - Country:US
Mailing Address - Phone:212-879-4900
Mailing Address - Fax:
Practice Address - Street 1:330 W 58TH ST STE 208
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1822
Practice Address - Country:US
Practice Address - Phone:347-725-0339
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-28
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22925103T00000X
IL071006957103TC2200X
NY018720103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent