Provider Demographics
NPI:1073895314
Name:SULLIVAN, JOHN P (LCSW-R)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:P
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 1:1545 SAINT PAUL ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14621-3156
Mailing Address - Country:US
Mailing Address - Phone:585-286-2824
Mailing Address - Fax:585-336-5880
Practice Address - Street 1:1545 SAINT PAUL ST
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14621-3156
Practice Address - Country:US
Practice Address - Phone:585-286-2824
Practice Address - Fax:585-336-5880
Is Sole Proprietor?:No
Enumeration Date:2011-09-13
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY043085104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker