Provider Demographics
NPI:1396973830
Name:SULLIVAN, PAULINE M (MED)
Entity type:Individual
Prefix:
First Name:PAULINE
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 552
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92033-0552
Mailing Address - Country:US
Mailing Address - Phone:442-300-4934
Mailing Address - Fax:
Practice Address - Street 1:1815 N BROADWAY APT 66
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-2066
Practice Address - Country:US
Practice Address - Phone:442-300-4934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-23
Last Update Date:2023-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MALMHC-4366101YP2500X
AZLPC-18621101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional