=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740082981
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LEO SULLIVAN MENTAL HEALTH COUNSELOR P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/26/2025
-----------------------------------------------------
Last Update Date | 08/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 100 DUFFY AVE
-----------------------------------------------------
City | HICKSVILLE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11801-3636
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-428-9881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19 CAROLINE CT
-----------------------------------------------------
City | NORTH BABYLON
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11703-1823
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 516-428-9881
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | SPORTS AND MENTAL PERFORMANCE COUNS
-----------------------------------------------------
Name | MR. LEO SULLIVAN
-----------------------------------------------------
Credential | LMHC
-----------------------------------------------------
Telephone | 516-428-9881
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101YM0800X
-----------------------------------------------------
Taxonomy Name | Mental Health Counselor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------