=====================================================
General NPI Number Information
=====================================================
NPI Number | 1508910449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SULLIVAN CENTER FOR CHILDREN A PSYCHOLOGICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/22/2007
-----------------------------------------------------
Last Update Date | 12/05/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3443 W SHAW AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93711-3204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-271-1186
-----------------------------------------------------
Fax | 559-271-8041
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3443 W SHAW AVE
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93711-3204
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-271-1186
-----------------------------------------------------
Fax | 559-271-8041
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL DIRECTOR
-----------------------------------------------------
Name | DR. KATHLEEN MARIE SULLIVAN
-----------------------------------------------------
Credential | PH.D.
-----------------------------------------------------
Telephone | 559-271-1186
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY14397
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY10706
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY13503
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY16553
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #5
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY17724
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #6
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY20803
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #7
-----------------------------------------------------
Taxonomy Code | 1041C0700X
-----------------------------------------------------
Taxonomy Name | Clinical Social Worker
-----------------------------------------------------
License Number | LCS19049
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #8
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC24833
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #9
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC42565
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #10
-----------------------------------------------------
Taxonomy Code | 106H00000X
-----------------------------------------------------
Taxonomy Name | Marriage & Family Therapist
-----------------------------------------------------
License Number | MFC42432
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #11
-----------------------------------------------------
Taxonomy Code | 2084P0804X
-----------------------------------------------------
Taxonomy Name | Child & Adolescent Psychiatry Physician
-----------------------------------------------------
License Number | G34063
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #12
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | PSY7395
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------