Healthcare Provider Details

I. General information

NPI: 1982488763
Provider Name (Legal Business Name): MARIE SULLIVAN CTRS, MBA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2023
Last Update Date: 08/22/2023
Certification Date: 08/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 MOHAWK ST
COHOES NY
12047-2629
US

IV. Provider business mailing address

55 MOHAWK ST
COHOES NY
12047-2629
US

V. Phone/Fax

Practice location:
  • Phone: 518-235-1100
  • Fax:
Mailing address:
  • Phone: 518-235-1100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: