Healthcare Provider Details

I. General information

NPI: 1245382365
Provider Name (Legal Business Name): GLORIA ROSE SULLIVAN MFTI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 04/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 G ST SUITE A
DAVIS CA
95616-3771
US

IV. Provider business mailing address

631 G ST SUITE A
DAVIS CA
95616-3725
US

V. Phone/Fax

Practice location:
  • Phone: 530-297-8085
  • Fax:
Mailing address:
  • Phone: 530-297-8085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number80574
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: