Provider Demographics
NPI:1558521005
Name:SULLIVAN, LISA MARIA (MFT)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIA
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6186 FERNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-5574
Mailing Address - Country:US
Mailing Address - Phone:714-875-7190
Mailing Address - Fax:
Practice Address - Street 1:1000 QUAIL ST
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2731
Practice Address - Country:US
Practice Address - Phone:714-875-7190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2008-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC 43533101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA10Medicaid