Provider Demographics
NPI:1720265796
Name:SULLIVAN, LAKEASHA GARNER (PHD)
Entity Type:Individual
Prefix:DR
First Name:LAKEASHA
Middle Name:GARNER
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:LAKEASHA
Other - Middle Name:
Other - Last Name:GARNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:304 W 115TH ST
Mailing Address - Street 2:2A
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10026-2350
Mailing Address - Country:US
Mailing Address - Phone:212-222-1754
Mailing Address - Fax:
Practice Address - Street 1:304 W 115TH ST
Practice Address - Street 2:2A
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10026-2350
Practice Address - Country:US
Practice Address - Phone:212-222-1754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017515103T00000X
GAPS-T001046103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103T00000XBehavioral Health & Social Service ProvidersPsychologist