Healthcare Provider Details

I. General information

NPI: 1063338994
Provider Name (Legal Business Name): JOHN MICHAEL SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/25/2026
Last Update Date: 06/25/2026
Certification Date: 06/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2004 ROUTE 17M
GOSHEN NY
10924-5210
US

IV. Provider business mailing address

25 TERBAR LOOP
NEW PALTZ NY
12561-4028
US

V. Phone/Fax

Practice location:
  • Phone: 845-294-0661
  • Fax:
Mailing address:
  • Phone: 516-376-6527
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number000917
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: