Provider Demographics
NPI:1467509448
Name:SULLIVAN, WILLIAM JOSEPH (MFT)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15442 CAMINO DEL PARQUE RD S
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-9655
Mailing Address - Country:US
Mailing Address - Phone:209-533-1126
Mailing Address - Fax:
Practice Address - Street 1:101 S FOREST RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-4895
Practice Address - Country:US
Practice Address - Phone:209-533-0963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFT 39899101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional