Healthcare Provider Details

I. General information

NPI: 1235335803
Provider Name (Legal Business Name): VIRGINIA MARY SULLIVAN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/21/2007
Last Update Date: 12/02/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2055 KELLOGG AVE
CORONA CA
92879-3111
US

IV. Provider business mailing address

387 MAGNOLIA AVE STE 103-406
CORONA CA
92879-3307
US

V. Phone/Fax

Practice location:
  • Phone: 951-898-7171
  • Fax:
Mailing address:
  • Phone: 951-518-2312
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number12546
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number17121
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: