Provider Demographics
NPI:1235335803
Name:SULLIVAN, VIRGINIA MARY (PHD)
Entity Type:Individual
Prefix:DR
First Name:VIRGINIA
Middle Name:MARY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:387 MAGNOLIA AVE STE 103-406
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3307
Mailing Address - Country:US
Mailing Address - Phone:951-518-2312
Mailing Address - Fax:
Practice Address - Street 1:2055 KELLOGG AVE
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92879-3111
Practice Address - Country:US
Practice Address - Phone:951-898-7171
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17121106H00000X
CA12546103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist