Provider Demographics
NPI:1164496931
Name:SULLIVAN, JOAN LUCILLE (MA, OTR, CHT)
Entity Type:Individual
Prefix:MS
First Name:JOAN
Middle Name:LUCILLE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA, OTR, CHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:74 SMITH AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH NYACK
Mailing Address - State:NY
Mailing Address - Zip Code:10960-4734
Mailing Address - Country:US
Mailing Address - Phone:845-358-6044
Mailing Address - Fax:
Practice Address - Street 1:503 GRASSLANDS RD
Practice Address - Street 2:SUITE 105
Practice Address - City:VALHALLA
Practice Address - State:NY
Practice Address - Zip Code:10595-1503
Practice Address - Country:US
Practice Address - Phone:914-345-9133
Practice Address - Fax:914-345-9140
Is Sole Proprietor?:No
Enumeration Date:2006-02-16
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000779-1225XH1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XH1200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistHand
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYQ66621Medicare PIN
NY4177910001Medicare NSC