| Doctor Name: | LAURA SULLIVAN |
| NPI Number: | 1881066785 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | CASAC-T |
| License Number: | |
| Business Practice Address: | 380 Freeville Rd Freeville, NY - 130689684 |
| Business Phone Number: | 6078446495 |
| Business Fax Number: | 6078443524 |
| Mailing Address: | 380 Freeville Rd, FREEVILLE |
| State: | NY |
| Postal Code: | 130689684 |
| Phone Number: | 6078446495 |
| Fax Number: | 6078443524 |
| NPI Enumeration Date: | 10/30/2015 |
| NPI Last Update Date: | 10/30/2015 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 101YA0400X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Counselor |
| Taxonomy Specialization: | Addiction (Substance Use Disorder) |
| Taxonomy Definition: | |