Provider Demographics
NPI:1225253909
Name:SULLIVAN, SANDRA KAY (ATR)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:KAY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:ATR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:670 PLACERVILLE DRIVE SUITE 2
Mailing Address - Street 2:
Mailing Address - City:PLACERVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95667
Mailing Address - Country:US
Mailing Address - Phone:530-644-2412
Mailing Address - Fax:
Practice Address - Street 1:670 PLACERVILLE DR STE 2
Practice Address - Street 2:
Practice Address - City:PLACERVILLE
Practice Address - State:CA
Practice Address - Zip Code:95667-4200
Practice Address - Country:US
Practice Address - Phone:530-644-2412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4969101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor