Provider Demographics
NPI:1336486414
Name:SULLIVAN, LISA (LCSW)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 INDUSTRIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-2220
Mailing Address - Country:US
Mailing Address - Phone:631-205-6232
Mailing Address - Fax:631-924-4454
Practice Address - Street 1:31 INDUSTRIAL BLVD
Practice Address - Street 2:
Practice Address - City:MEDFORD
Practice Address - State:NY
Practice Address - Zip Code:11763-2220
Practice Address - Country:US
Practice Address - Phone:631-205-6232
Practice Address - Fax:631-924-4454
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-10
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY083436-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical