Provider Demographics
NPI:1871246462
Name:SULLIVAN, TYESHA T (LMFT)
Entity Type:Individual
Prefix:MRS
First Name:TYESHA
Middle Name:T
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4447 ABRUZZI CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95206-6097
Mailing Address - Country:US
Mailing Address - Phone:209-818-4711
Mailing Address - Fax:
Practice Address - Street 1:540 N CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95202-2117
Practice Address - Country:US
Practice Address - Phone:209-464-4524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-02
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA123866106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist