Provider Demographics
NPI:1972910750
Name:SULLIVAN, LAURA (LCSW)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:
Last Name:SULLIVAN
Suffix:
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 1:350 E GOBBI ST
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5511
Mailing Address - Country:US
Mailing Address - Phone:707-467-2010
Mailing Address - Fax:707-462-6994
Practice Address - Street 1:140 GIBSON ST
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482
Practice Address - Country:US
Practice Address - Phone:707-468-5536
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-14
Last Update Date:2018-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA79901171M00000X, 1041C0700X
CAASW 59134171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No171M00000XOther Service ProvidersCase Manager/Care Coordinator