Provider Demographics
NPI:1609315423
Name:SULLIVAN COUNSELING INCORPORATED
Entity Type:Organization
Organization Name:SULLIVAN COUNSELING INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:JOANN
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:LMFT
Authorized Official - Phone:516-662-1158
Mailing Address - Street 1:21 GREENE AVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-2943
Mailing Address - Country:US
Mailing Address - Phone:516-743-8571
Mailing Address - Fax:
Practice Address - Street 1:1024 N HAMILTON AVE
Practice Address - Street 2:
Practice Address - City:LINDENHURST
Practice Address - State:NY
Practice Address - Zip Code:11757-2129
Practice Address - Country:US
Practice Address - Phone:516-662-1158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-02-13
Last Update Date:2017-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001177302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization