Provider Demographics
NPI:1982488763
Name:SULLIVAN, MARIE (CTRS, MBA)
Entity type:Individual
Prefix:
First Name:MARIE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:CTRS, MBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:55 MOHAWK ST
Mailing Address - Street 2:
Mailing Address - City:COHOES
Mailing Address - State:NY
Mailing Address - Zip Code:12047-2629
Mailing Address - Country:US
Mailing Address - Phone:518-235-1100
Mailing Address - Fax:
Practice Address - Street 1:55 MOHAWK ST
Practice Address - Street 2:
Practice Address - City:COHOES
Practice Address - State:NY
Practice Address - Zip Code:12047-2629
Practice Address - Country:US
Practice Address - Phone:518-235-1100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY225800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225800000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRecreation Therapist