Provider Demographics
NPI:1861605156
Name:SULLIVAN, MARTIN (LPC)
Entity type:Individual
Prefix:MR
First Name:MARTIN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32 BUENA VISTA AVE
Mailing Address - Street 2:
Mailing Address - City:FAIR HAVEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07704-3526
Mailing Address - Country:US
Mailing Address - Phone:732-996-9072
Mailing Address - Fax:732-530-4534
Practice Address - Street 1:41 RECKLESS PL
Practice Address - Street 2:
Practice Address - City:RED BANK
Practice Address - State:NJ
Practice Address - Zip Code:07701-1703
Practice Address - Country:US
Practice Address - Phone:732-996-9072
Practice Address - Fax:732-530-4534
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37PC00315100101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0043532Medicaid