Provider Demographics
NPI:1881066785
Name:SULLIVAN, LAURA (LCSW, CASAC)
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:LCSW, CASAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 E FALLS ST # 1
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-3705
Mailing Address - Country:US
Mailing Address - Phone:607-342-3451
Mailing Address - Fax:
Practice Address - Street 1:305 E FALLS ST # 1
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-3705
Practice Address - Country:US
Practice Address - Phone:607-342-3451
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-30
Last Update Date:2025-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY29392101YA0400X
NY0939371041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)