Provider Demographics
NPI:1992384200
Name:SULLIVAN, GEORGE JOHN III
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:JOHN
Last Name:SULLIVAN
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SOUNDWAY DR
Mailing Address - Street 2:
Mailing Address - City:ROCKY POINT
Mailing Address - State:NY
Mailing Address - Zip Code:11778-9001
Mailing Address - Country:US
Mailing Address - Phone:631-741-4988
Mailing Address - Fax:
Practice Address - Street 1:208 ROANOKE AVE
Practice Address - Street 2:
Practice Address - City:RIVERHEAD
Practice Address - State:NY
Practice Address - Zip Code:11901-2706
Practice Address - Country:US
Practice Address - Phone:631-357-0173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-05
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TR0400XBehavioral Health & Social Service ProvidersPsychologistRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYK6043576401OtherEMBLEM HEALTH