Provider Demographics
NPI:1659582377
Name:SULLIVAN, ALICE R (PTA)
Entity Type:Individual
Prefix:
First Name:ALICE
Middle Name:R
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 HUNT DR
Mailing Address - Street 2:
Mailing Address - City:FLORIDA
Mailing Address - State:NY
Mailing Address - Zip Code:10921-3015
Mailing Address - Country:US
Mailing Address - Phone:845-651-7396
Mailing Address - Fax:
Practice Address - Street 1:121 DUNNING RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:NY
Practice Address - Zip Code:10940-2243
Practice Address - Country:US
Practice Address - Phone:845-343-0801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY004610-1313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility