Provider Demographics
NPI:1619112828
Name:SULLIVAN, NANCY ANNE (LCSW)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:ANNE
Other - Last Name:WATTS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LCSW
Mailing Address - Street 1:15913 HORACE HARDING EXPY
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11365-1424
Mailing Address - Country:US
Mailing Address - Phone:917-575-2344
Mailing Address - Fax:718-262-1447
Practice Address - Street 1:9729 64TH RD
Practice Address - Street 2:
Practice Address - City:REGO PARK
Practice Address - State:NY
Practice Address - Zip Code:11374-2240
Practice Address - Country:US
Practice Address - Phone:718-896-3400
Practice Address - Fax:718-459-5621
Is Sole Proprietor?:No
Enumeration Date:2008-12-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0754771041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00244019Medicaid