Healthcare Provider Details

I. General information

NPI: 1376164012
Provider Name (Legal Business Name): MATTHEW CONOR SULLIVAN PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2020
Last Update Date: 08/17/2026
Certification Date: 08/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 COLUMBUS CIR
NEW YORK NY
10019-1412
US

IV. Provider business mailing address

5 COLUMBUS CIR
NEW YORK NY
10019-1412
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-6001
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number7145
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License NumberPSY11773
License Number StateMA
# 3
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number004880
License Number StateCT
# 4
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number026830
License Number StateNY
# 5
Primary TaxonomyN
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number35SI00767600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: