Healthcare Provider Details

I. General information

NPI: 1275203440
Provider Name (Legal Business Name): CORY R SULLINS PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 12/07/2025
Certification Date: 09/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 NORTHCREST DR STE 2
CRESCENT CITY CA
95531-2322
US

IV. Provider business mailing address

3319 ALAMEDA ST
MEDFORD OR
97504-9635
US

V. Phone/Fax

Practice location:
  • Phone: 310-901-1996
  • Fax: 707-306-7255
Mailing address:
  • Phone: 310-901-1996
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number32846
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: