Provider Demographics
NPI:1104988062
Name:SULLIVAN, EMILY ELIZABETH
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:ELIZABETH
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 ALICE LN APT 7
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-5151
Mailing Address - Country:US
Mailing Address - Phone:650-617-3870
Mailing Address - Fax:
Practice Address - Street 1:650 CLARK WAY
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94304-2300
Practice Address - Country:US
Practice Address - Phone:650-617-3870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA41604106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist