Healthcare Provider Details

I. General information

NPI: 1831932516
Provider Name (Legal Business Name): JOANNA LEAH SULLIVAN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2024
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4785 N 1ST ST
FRESNO CA
93726-0500
US

IV. Provider business mailing address

PO BOX 321
CLOVIS CA
93613-0321
US

V. Phone/Fax

Practice location:
  • Phone: 559-448-4620
  • Fax:
Mailing address:
  • Phone: 651-728-2415
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY35536
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number13678529-2501
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: