Provider Demographics
NPI:1588694434
Name:SULLIVAN, RICHARD M (LCSW-R)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5420 SHIMERVILLE RD
Mailing Address - Street 2:
Mailing Address - City:CLARENCE
Mailing Address - State:NY
Mailing Address - Zip Code:14031-1118
Mailing Address - Country:US
Mailing Address - Phone:716-741-2138
Mailing Address - Fax:
Practice Address - Street 1:5420 SHIMERVILLE RD
Practice Address - Street 2:
Practice Address - City:CLARENCE
Practice Address - State:NY
Practice Address - Zip Code:14031-1118
Practice Address - Country:US
Practice Address - Phone:716-741-2138
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2007-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0138061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00052410001OtherUNIVERA
NY000528842001OtherBLUE CROSS & BLUE SHIELD
NY6290360OtherINDEPENDENT HEALTH
NY7484558OtherGHI
NY7484558OtherGHI