MEDICARE: ELIZABETH ROCKETT SULLIVAN BCBA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst
2	103K00000X	Behavior Analyst	1-20-44411	CA

General Provider Information

NPI Number	:	1528674090
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ELIZABETH ROCKETT SULLIVAN BCBA

Provider Business Mailing Address
First Line	:	990 HIGHLAND DR STE 310
Second Line	:
City	:	SOLANA BEACH
State	:	CA
Zip	:	92075-2438
Country	:	US
Telephone Number	:	619-961-2015
Fax Number	:

Provider Business Practice Location Address
First Line	:	990 HIGHLAND DR STE 310
Second Line	:
City	:	SOLANA BEACH
State	:	CA
Zip	:	92075-2438
Country	:	US
Telephone Number	:	619-961-2015
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2020
Last Update Date	:	11/27/2023

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