Provider Demographics
NPI:1619639473
Name:SULLIVAN, LISA (PHD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18625 MACALPINE LOOP
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-9366
Mailing Address - Country:US
Mailing Address - Phone:760-672-1787
Mailing Address - Fax:
Practice Address - Street 1:18625 MACALPINE LOOP
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-9366
Practice Address - Country:US
Practice Address - Phone:760-672-1787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-08
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA17800103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist