MEDICARE: LISA SULLBERG

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	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1639547474
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA SULLBERG

Provider Business Mailing Address
First Line	:	852 AVENUE D
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94130-2002
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	852 AVENUE D
Second Line	:
City	:	SAN FRANCISCO
State	:	CA
Zip	:	94130-2002
Country	:	US
Telephone Number	:	415-217-8418
Fax Number	:

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

Provider Enumeration Date	:	09/10/2015
Last Update Date	:	09/10/2015

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Directions to “ LISA SULLBERG ” Practice Location

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