Provider Demographics
NPI:1245382365
Name:SULLIVAN, GLORIA ROSE (MFTI)
Entity Type:Individual
Prefix:MRS
First Name:GLORIA
Middle Name:ROSE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MFTI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:631 G ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-3725
Mailing Address - Country:US
Mailing Address - Phone:530-297-8085
Mailing Address - Fax:
Practice Address - Street 1:613 G ST
Practice Address - Street 2:SUITE A
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-3771
Practice Address - Country:US
Practice Address - Phone:530-297-8085
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2016-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80574106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2897Medicare ID - Type Unspecified