Provider Demographics
NPI:1003926155
Name:SULLIVAN, MARILEE
Entity Type:Individual
Prefix:
First Name:MARILEE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARILEE
Other - Middle Name:
Other - Last Name:EVANS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MS MFT
Mailing Address - Street 1:6147 SUTTER AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-2738
Mailing Address - Country:US
Mailing Address - Phone:916-971-7640
Mailing Address - Fax:916-971-5711
Practice Address - Street 1:6147 SUTTER AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-2738
Practice Address - Country:US
Practice Address - Phone:916-971-7640
Practice Address - Fax:916-971-5711
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 16080106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist