Provider Demographics
NPI:1366918617
Name:SULLIVAN, MICHAEL DAVID
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:DAVID
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 1/2 HECTOR ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-2025
Mailing Address - Country:US
Mailing Address - Phone:724-704-1719
Mailing Address - Fax:
Practice Address - Street 1:403 1/2 HECTOR ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-2025
Practice Address - Country:US
Practice Address - Phone:724-704-1719
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2019-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY087166104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker