Provider Demographics
NPI:1124579370
Name:SULLIVAN, LYDIA
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 WYCKOFF AVE
Mailing Address - Street 2:
Mailing Address - City:RAMSEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07446-2251
Mailing Address - Country:US
Mailing Address - Phone:845-893-0066
Mailing Address - Fax:
Practice Address - Street 1:721 SOUTH BLVD
Practice Address - Street 2:SUITE 210
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-2982
Practice Address - Country:US
Practice Address - Phone:312-404-7225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-21
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL11623077103K00000X
NJ11623077103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst