Provider Demographics
NPI:1184861882
Name:SULLIVAN, LAURA JEAN (PSYD)
Entity Type:Individual
Prefix:DR
First Name:LAURA
Middle Name:JEAN
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:PO BOX 6781
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95763-6781
Mailing Address - Country:US
Mailing Address - Phone:916-985-8610
Mailing Address - Fax:
Practice Address - Street 1:100 PRISON RD
Practice Address - Street 2:
Practice Address - City:REPRESA
Practice Address - State:CA
Practice Address - Zip Code:95671-3000
Practice Address - Country:US
Practice Address - Phone:916-985-8610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2009-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 22206103TF0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TF0200XBehavioral Health & Social Service ProvidersPsychologistForensic