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General NPI Number Information
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NPI Number | 1235335803
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Entity Type | Individual
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Provider Name | VIRGINIA MARY SULLIVAN PHD
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Gender | Female
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Dates
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Enumeration Date | 06/21/2007
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Last Update Date | 12/02/2021
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Provider Practice Location Address
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Address Line | 2055 KELLOGG AVE
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City | CORONA
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State | CA
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Zip | 92879-3111
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Country | US
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Telephone | 951-898-7171
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Fax |
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Provider Business Mailing Address
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Address Line | 387 MAGNOLIA AVE STE 103-406
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City | CORONA
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State | CA
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Zip | 92879-3307
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Country | US
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Telephone | 951-518-2312
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number | 17121
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 103T00000X
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Taxonomy Name | Psychologist
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License Number | 12546
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License Number State | CA
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