Provider Demographics
NPI:1679669287
Name:SULLUM, DAVID MOSHE (PHD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:MOSHE
Last Name:SULLUM
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 MIRON DRIVE
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12603
Mailing Address - Country:US
Mailing Address - Phone:845-462-1259
Mailing Address - Fax:
Practice Address - Street 1:2 MIRON DRIVE
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12603
Practice Address - Country:US
Practice Address - Phone:845-462-1259
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010911-1103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01450086Medicaid
NYV5H731Medicare ID - Type UnspecifiedPSYCHOLOGIST