Healthcare Provider Details

I. General information

NPI: 1780319319
Provider Name (Legal Business Name): JOSHUA PATRICK SULLIVAN LCSW
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 05/15/2026
Certification Date: 05/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

503 FAIR OAKS AVE
SOUTH PASADENA CA
91030
US

IV. Provider business mailing address

3848 GLENFELIZ BLVD
LOS ANGELES CA
90039-1742
US

V. Phone/Fax

Practice location:
  • Phone: 909-363-6937
  • Fax:
Mailing address:
  • Phone: 909-363-6937
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number136850
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: