Healthcare Provider Details

I. General information

NPI: 1841313145
Provider Name (Legal Business Name): SUSAN SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7841 EL CAJON BLVD
LA MESA CA
91941-3709
US

IV. Provider business mailing address

3612 4TH AVE
SAN DIEGO CA
92103-4106
US

V. Phone/Fax

Practice location:
  • Phone: 619-697-2038
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: