Provider Demographics
NPI:1790958254
Name:PHILLIPS-SULLIVAN, LISA GAIL (ART THERAPIST)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GAIL
Last Name:PHILLIPS-SULLIVAN
Suffix:
Gender:F
Credentials:ART THERAPIST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 SHORE RD
Mailing Address - Street 2:#417
Mailing Address - City:LONG BEACH
Mailing Address - State:NY
Mailing Address - Zip Code:11561-4677
Mailing Address - Country:US
Mailing Address - Phone:516-319-5993
Mailing Address - Fax:
Practice Address - Street 1:630 SHORE RD
Practice Address - Street 2:#417
Practice Address - City:LONG BEACH
Practice Address - State:NY
Practice Address - Zip Code:11561-4677
Practice Address - Country:US
Practice Address - Phone:516-319-5993
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-04
Last Update Date:2008-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000018174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist