=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134852601
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LILYANA MARY SULLIVAN LMSW
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2022
-----------------------------------------------------
Last Update Date | 07/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 LAUREL RD
-----------------------------------------------------
City | EAST NORTHPORT
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11731-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-962-1191
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4 TREDWELL AVE APT 3
-----------------------------------------------------
City | SYOSSET
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11791-3049
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-747-0907
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 104100000X
-----------------------------------------------------
Taxonomy Name | Social Worker
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------