Provider Demographics
NPI:1134212491
Name:SULLIVAN, J DONNA (LCSW, C-ASWCM)
Entity type:Individual
Prefix:
First Name:J DONNA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW, C-ASWCM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:156B HERITAGE HLS
Mailing Address - Street 2:
Mailing Address - City:SOMERS
Mailing Address - State:NY
Mailing Address - Zip Code:10589-1117
Mailing Address - Country:US
Mailing Address - Phone:914-276-0729
Mailing Address - Fax:
Practice Address - Street 1:52 N BROADWAY
Practice Address - Street 2:
Practice Address - City:WHITE PLAINS
Practice Address - State:NY
Practice Address - Zip Code:10603-3710
Practice Address - Country:US
Practice Address - Phone:914-260-1874
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR047695-11041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYN5X401Medicare ID - Type Unspecified