Provider Demographics
NPI:1275203440
Name:SULLINS, CORY R (PHD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:R
Last Name:SULLINS
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3319 ALAMEDA ST
Mailing Address - Street 2:
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-9635
Mailing Address - Country:US
Mailing Address - Phone:310-901-1996
Mailing Address - Fax:
Practice Address - Street 1:1305 NORTHCREST DR STE 2
Practice Address - Street 2:
Practice Address - City:CRESCENT CITY
Practice Address - State:CA
Practice Address - Zip Code:95531-2322
Practice Address - Country:US
Practice Address - Phone:310-901-1996
Practice Address - Fax:707-306-7255
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-17
Last Update Date:2021-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA32846103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Single Specialty