Provider Demographics
NPI:1790523082
Name:SULLIVAN, DANIEL JACOB (PMHNP)
Entity type:Individual
Prefix:
First Name:DANIEL
Middle Name:JACOB
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 FRIAR TUCK WAY
Mailing Address - Street 2:
Mailing Address - City:SARATOGA SPRINGS
Mailing Address - State:NY
Mailing Address - Zip Code:12866-6164
Mailing Address - Country:US
Mailing Address - Phone:518-222-5586
Mailing Address - Fax:
Practice Address - Street 1:30 CRESCENT AVE
Practice Address - Street 2:
Practice Address - City:SARATOGA SPRINGS
Practice Address - State:NY
Practice Address - Zip Code:12866-5142
Practice Address - Country:US
Practice Address - Phone:518-584-3600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-19
Last Update Date:2024-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY406165363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health