Provider Demographics
NPI:1235279209
Name:SULLIVAN, PATRICK JOSEPH (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11020 71ST RD
Mailing Address - Street 2:SUITE 111
Mailing Address - City:FOREST HILLS
Mailing Address - State:NY
Mailing Address - Zip Code:11375-4945
Mailing Address - Country:US
Mailing Address - Phone:718-793-3313
Mailing Address - Fax:718-793-2023
Practice Address - Street 1:11020 71ST RD
Practice Address - Street 2:SUITE 111
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4945
Practice Address - Country:US
Practice Address - Phone:718-793-3313
Practice Address - Fax:718-793-2023
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR0409031041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4156PHMedicare ID - Type Unspecified
NYS16506Medicare UPIN