Healthcare Provider Details

I. General information

NPI: 1588694434
Provider Name (Legal Business Name): RICHARD M SULLIVAN LCSW-R
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/04/2006
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 SHIMERVILLE RD
CLARENCE NY
14031-1118
US

IV. Provider business mailing address

5420 SHIMERVILLE RD
CLARENCE NY
14031-1118
US

V. Phone/Fax

Practice location:
  • Phone: 716-741-2138
  • Fax:
Mailing address:
  • Phone: 716-741-2138
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number013806
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: