Provider Demographics
NPI:1578711644
Name:SULLIVAN, DESMOND JAMES (CASAC)
Entity Type:Individual
Prefix:MR
First Name:DESMOND
Middle Name:JAMES
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:CASAC
Other - Prefix:
Other - First Name:DESMOND
Other - Middle Name:JAMES
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CASAC 12582
Mailing Address - Street 1:1310 ROCKAWAY PKWY
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11236-2339
Mailing Address - Country:US
Mailing Address - Phone:718-257-3880
Mailing Address - Fax:718-257-3580
Practice Address - Street 1:1310 ROCKAWAY PKWY
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11236-2339
Practice Address - Country:US
Practice Address - Phone:718-257-3880
Practice Address - Fax:718-257-3580
Is Sole Proprietor?:No
Enumeration Date:2008-09-03
Last Update Date:2008-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY12582101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)