Provider Demographics
NPI:1932320348
Name:SULLIVAN, WILLIAM JOSEPH (COTA)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SYRACUSE AVE
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:NY
Mailing Address - Zip Code:11763-3126
Mailing Address - Country:US
Mailing Address - Phone:631-758-2824
Mailing Address - Fax:
Practice Address - Street 1:200 BELLE TERRE RD
Practice Address - Street 2:
Practice Address - City:PORT JEFFERSON
Practice Address - State:NY
Practice Address - Zip Code:11777-1928
Practice Address - Country:US
Practice Address - Phone:631-474-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1052118224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant