Healthcare Provider Details

I. General information

NPI: 1588782593
Provider Name (Legal Business Name): GAVIN O'SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

840 OLD GRASS VALLEY RD
COLFAX CA
95713-9407
US

IV. Provider business mailing address

PO BOX 133
COLFAX CA
95713-0133
US

V. Phone/Fax

Practice location:
  • Phone: 530-217-3575
  • Fax:
Mailing address:
  • Phone: 530-217-3575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberLCSW69682
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: