Provider Demographics
NPI:1689432916
Name:SULLIVAN-BOILEAU, MEGAN LEE (PHD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:LEE
Last Name:SULLIVAN-BOILEAU
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:LEE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:535 MISSISSIPPI ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94107-2934
Mailing Address - Country:US
Mailing Address - Phone:818-384-0746
Mailing Address - Fax:
Practice Address - Street 1:2542 S BASCOM AVE STE 100
Practice Address - Street 2:
Practice Address - City:CAMPBELL
Practice Address - State:CA
Practice Address - Zip Code:95008-5541
Practice Address - Country:US
Practice Address - Phone:559-574-3002
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-03-11
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSB94027848103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical