Provider Demographics
NPI:1578047031
Name:SULLIVAN, MARY BETH (SPED)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:BETH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:SPED
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:BETH
Other - Last Name:SHEWMAKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1 ODELL PLZ STE 263
Mailing Address - Street 2:
Mailing Address - City:YONKERS
Mailing Address - State:NY
Mailing Address - Zip Code:10701-1402
Mailing Address - Country:US
Mailing Address - Phone:914-965-1152
Mailing Address - Fax:914-965-1419
Practice Address - Street 1:1 ODELL PLZ STE 263
Practice Address - Street 2:
Practice Address - City:YONKERS
Practice Address - State:NY
Practice Address - Zip Code:10701-1402
Practice Address - Country:US
Practice Address - Phone:914-965-1152
Practice Address - Fax:914-965-1419
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1238212181174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist