Provider Demographics
NPI:1013626324
Name:SULLIVAN, SANDRA MARIE (LMSW)
Entity type:Individual
Prefix:
First Name:SANDRA
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 1:2570 ROUTE 9W STE 10
Mailing Address - Street 2:
Mailing Address - City:CORNWALL
Mailing Address - State:NY
Mailing Address - Zip Code:12518-1370
Mailing Address - Country:US
Mailing Address - Phone:845-220-3100
Mailing Address - Fax:845-534-2940
Practice Address - Street 1:275 CHENANGO ST
Practice Address - Street 2:
Practice Address - City:BINGHAMTON
Practice Address - State:NY
Practice Address - Zip Code:13901-2312
Practice Address - Country:US
Practice Address - Phone:607-201-1204
Practice Address - Fax:607-201-1201
Is Sole Proprietor?:No
Enumeration Date:2022-11-16
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109248104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker