Provider Demographics
NPI:1508946484
Name:SULLIVAN, ANDREA MARY (DC, CCSP)
Entity Type:Individual
Prefix:MS
First Name:ANDREA
Middle Name:MARY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DC, CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 LAKESHORE AVE STE E
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94606-1188
Mailing Address - Country:US
Mailing Address - Phone:510-893-1577
Mailing Address - Fax:510-893-8907
Practice Address - Street 1:2100 LAKESHORE AVE STE E
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94606-1188
Practice Address - Country:US
Practice Address - Phone:510-893-1577
Practice Address - Fax:510-893-8907
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20808111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU17167Medicare UPIN
CADC0208080Medicare ID - Type Unspecified