Healthcare Provider Details

I. General information

NPI: 1821071481
Provider Name (Legal Business Name): ELIZABETH SULLIVAN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 12/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5199 E PACIFIC COAST HWY STE 612
LONG BEACH CA
90804-3366
US

IV. Provider business mailing address

642 N HAYWORTH AVE APT 9
LOS ANGELES CA
90048-2339
US

V. Phone/Fax

Practice location:
  • Phone: 213-437-3569
  • Fax:
Mailing address:
  • Phone: 312-330-3845
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY28723
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: