Provider Demographics
NPI:1750662680
Name:SULLIVAN, LISA WORDEN (PHD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:WORDEN
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 1:1177 HIGH RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06905-1221
Mailing Address - Country:US
Mailing Address - Phone:203-609-5692
Mailing Address - Fax:203-569-9747
Practice Address - Street 1:1177 HIGH RIDGE RD
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-1221
Practice Address - Country:US
Practice Address - Phone:203-609-5692
Practice Address - Fax:203-569-9747
Is Sole Proprietor?:Yes
Enumeration Date:2011-09-06
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003117103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling