Provider Demographics
NPI:1346634151
Name:SULLIVAN, TAMARA (LMHC)
Entity Type:Individual
Prefix:DR
First Name:TAMARA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4107 LAKE RD N
Mailing Address - Street 2:
Mailing Address - City:BROCKPORT
Mailing Address - State:NY
Mailing Address - Zip Code:14420-1519
Mailing Address - Country:US
Mailing Address - Phone:585-329-7853
Mailing Address - Fax:
Practice Address - Street 1:4107 LAKE RD N
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1519
Practice Address - Country:US
Practice Address - Phone:585-329-7853
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-19
Last Update Date:2015-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY005955-1101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health