Healthcare Provider Details

I. General information

NPI: 1215426408
Provider Name (Legal Business Name): ROBERT JOSEPH SULLIVAN LMHC, PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/03/2018
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 MADISON AVE RM 2000
NEW YORK NY
10017-5416
US

IV. Provider business mailing address

112 MULLER AVE
STATEN ISLAND NY
10314-2037
US

V. Phone/Fax

Practice location:
  • Phone: 718-704-4008
  • Fax:
Mailing address:
  • Phone: 718-704-4008
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number408810
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number010509
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number837821
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: