Provider Demographics
NPI:1760735948
Name:SULLIVAN, MEGAN MARIE (LMSW)
Entity Type:Individual
Prefix:MS
First Name:MEGAN
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1128 VESTAL AVE
Mailing Address - Street 2:
Mailing Address - City:BINGHAMTON
Mailing Address - State:NY
Mailing Address - Zip Code:13903-1528
Mailing Address - Country:US
Mailing Address - Phone:607-724-0416
Mailing Address - Fax:
Practice Address - Street 1:1128 VESTAL AVE
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13903-1528
Practice Address - Country:US
Practice Address - Phone:607-724-0416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-24
Last Update Date:2012-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY065934104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker