Provider Demographics
NPI:1487633616
Name:LAMPHERE SULLIVAN, GEORGINA INES (PHD)
Entity Type:Individual
Prefix:DR
First Name:GEORGINA
Middle Name:INES
Last Name:LAMPHERE SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:GEORGINA
Other - Middle Name:INES
Other - Last Name:LAMPHERE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PHD
Mailing Address - Street 1:8253 WHITE OAK AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-7671
Mailing Address - Country:US
Mailing Address - Phone:909-987-1997
Mailing Address - Fax:909-978-0993
Practice Address - Street 1:8253 WHITE OAK AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-7671
Practice Address - Country:US
Practice Address - Phone:909-987-1997
Practice Address - Fax:909-978-0993
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-16
Last Update Date:2019-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY 10649103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPSY 10649OtherPH.D. LICENSE
CAPSY 10649OtherPH.D. LICENSE