MEDICARE: DR. ELIZABETH SULLIVAN PSY.D.

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	390200000X	Student in an Organized Health Care Education/Training Program
2	103TC0700X	Clinical Psychologist	PSY28723	CA

General Provider Information

NPI Number	:	1821071481
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ELIZABETH SULLIVAN PSY.D.

Provider Business Mailing Address
First Line	:	642 N HAYWORTH AVE APT 9
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90048-2339
Country	:	US
Telephone Number	:	312-330-3845
Fax Number	:

Provider Business Practice Location Address
First Line	:	5199 E PACIFIC COAST HWY STE 612
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90804-3366
Country	:	US
Telephone Number	:	213-437-3569
Fax Number	:

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

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	12/03/2019

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