MEDICARE: LISA GAIL PHILLIPS-SULLIVAN ART THERAPIST

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	174400000X	Specialist	000018	NY

General Provider Information

NPI Number	:	1790958254
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA GAIL PHILLIPS-SULLIVAN ART THERAPIST

Provider Business Mailing Address
First Line	:	630 SHORE RD
Second Line	:	#417
City	:	LONG BEACH
State	:	NY
Zip	:	11561-4677
Country	:	US
Telephone Number	:	516-319-5993
Fax Number	:

Provider Business Practice Location Address
First Line	:	630 SHORE RD
Second Line	:	#417
City	:	LONG BEACH
State	:	NY
Zip	:	11561-4677
Country	:	US
Telephone Number	:	516-319-5993
Fax Number	:

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

Provider Enumeration Date	:	04/04/2008
Last Update Date	:	04/04/2008

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