Provider Demographics
NPI:1508910449
Name:SULLIVAN CENTER FOR CHILDREN A PSYCHOLOGICAL CORPORATION
Entity Type:Organization
Organization Name:SULLIVAN CENTER FOR CHILDREN A PSYCHOLOGICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CLINICAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:559-271-1186
Mailing Address - Street 1:3443 W SHAW AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-3204
Mailing Address - Country:US
Mailing Address - Phone:559-271-1186
Mailing Address - Fax:559-271-8041
Practice Address - Street 1:3443 W SHAW AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3204
Practice Address - Country:US
Practice Address - Phone:559-271-1186
Practice Address - Fax:559-271-8041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-22
Last Update Date:2018-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY7395103TC0700X
CAPSY14397103TC0700X
CAPSY10706103TC0700X
CAPSY13503103TC0700X
CAPSY16553103TC0700X
CAPSY17724103TC0700X
CAPSY20803103TC0700X
CALCS190491041C0700X
CAMFC24833106H00000X
CAMFC42565106H00000X
CAMFC42432106H00000X
CAG340632084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherTAX ID