Individual
GEORGE JOHN SULLIVAN III
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
208 ROANOKE AVE, RIVERHEAD, NY 11901-2706
(631) 357-0173
Mailing address
25 SOUNDWAY DR, ROCKY POINT, NY 11778-9001
(631) 741-4988
Taxonomy
Speciality
Code
Description
License number
State
103TR0400X
Rehabilitation Psychologist
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
K6043576401
EMBLEM HEALTH
NY
Enumeration date
04/05/2021
Last updated
04/05/2021
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