Provider Demographics
NPI:1356824486
Name:SULLIVAN, PAUL J
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:J
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CASAC
Mailing Address - Street 1:2H FULHAM RD
Mailing Address - Street 2:
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-6322
Mailing Address - Country:US
Mailing Address - Phone:518-244-0155
Mailing Address - Fax:
Practice Address - Street 1:11-12 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:GLOVERSVILLE
Practice Address - State:NY
Practice Address - Zip Code:12078
Practice Address - Country:US
Practice Address - Phone:518-725-4310
Practice Address - Fax:518-725-2556
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-14
Last Update Date:2018-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY28067101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$Medicaid