Provider Demographics
NPI:1750460499
Name:SULLY, SANDRA I (LCSW)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:
Last Name:SULLY
Suffix:I
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 E COMPTON BLVD
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90221-3303
Mailing Address - Country:US
Mailing Address - Phone:310-668-6857
Mailing Address - Fax:310-898-3473
Practice Address - Street 1:256 S ROBERTSON BLVD
Practice Address - Street 2:797
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90211-2811
Practice Address - Country:US
Practice Address - Phone:626-578-0419
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS102621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical