Provider Demographics
NPI:1831932516
Name:SULLIVAN, JOANNA LEAH (PSYD)
Entity type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:LEAH
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:PO BOX 1132
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-1132
Mailing Address - Country:US
Mailing Address - Phone:651-728-2415
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 1132
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-1132
Practice Address - Country:US
Practice Address - Phone:651-728-2415
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-18
Last Update Date:2024-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY35536103TC0700X
UT13678529-2501103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical