Provider Demographics
NPI:1073851663
Name:SULLIVAN, SANDRA JUDD (PSYD)
Entity Type:Individual
Prefix:DR
First Name:SANDRA
Middle Name:JUDD
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 CAMBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:BURLINGAME
Mailing Address - State:CA
Mailing Address - Zip Code:94010-3305
Mailing Address - Country:US
Mailing Address - Phone:650-762-6752
Mailing Address - Fax:
Practice Address - Street 1:155 BOVET RD
Practice Address - Street 2:SUITE 404
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3108
Practice Address - Country:US
Practice Address - Phone:650-762-6752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-01-16
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY20296103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical