Provider Demographics
NPI:1821071481
Name:SULLIVAN, ELIZABETH (PSYD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:642 N HAYWORTH AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90048-2339
Mailing Address - Country:US
Mailing Address - Phone:312-330-3845
Mailing Address - Fax:
Practice Address - Street 1:5199 E PACIFIC COAST HWY STE 612
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90804-3366
Practice Address - Country:US
Practice Address - Phone:213-437-3569
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-28
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPSY28723103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program