Provider Demographics
NPI:1437421591
Name:SULLIVAN, GARY S (LCSW)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:S
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 1:1726 SE 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:FT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2514
Mailing Address - Country:US
Mailing Address - Phone:954-522-4749
Mailing Address - Fax:954-522-9357
Practice Address - Street 1:501 SE 18TH CT
Practice Address - Street 2:
Practice Address - City:FT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2833
Practice Address - Country:US
Practice Address - Phone:954-522-4749
Practice Address - Fax:954-522-9357
Is Sole Proprietor?:No
Enumeration Date:2012-02-06
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW47431041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical