Provider Demographics
NPI:1427344167
Name:SULLIVAN, AMY JEAN
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:17 BOSCO DR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-3727
Mailing Address - Country:US
Mailing Address - Phone:845-532-1936
Mailing Address - Fax:
Practice Address - Street 1:139 CORNELL ST
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-3633
Practice Address - Country:US
Practice Address - Phone:845-338-1234
Practice Address - Fax:845-338-6284
Is Sole Proprietor?:No
Enumeration Date:2011-06-21
Last Update Date:2020-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY082906-1104100000X
NCC0097811041C0700X
101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No104100000XBehavioral Health & Social Service ProvidersSocial Worker
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical