MEDICARE: CASSANDRA SULLIVAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator	1275656	NY

General Provider Information

NPI Number	:	1528763539
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CASSANDRA SULLIVAN

Provider Business Mailing Address
First Line	:	39 INDIANA AVE
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1207
Country	:	US
Telephone Number	:	845-978-5033
Fax Number	:

Provider Business Practice Location Address
First Line	:	39 INDIANA AVE
Second Line	:
City	:	LONG BEACH
State	:	NY
Zip	:	11561-1207
Country	:	US
Telephone Number	:	845-978-5033
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/31/2023
Last Update Date	:	08/16/2023

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