Provider Demographics
NPI:1215902812
Name:SULLIVAN, AMELIA OWENS (MFT)
Entity type:Individual
Prefix:
First Name:AMELIA
Middle Name:OWENS
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1750 FRANCISCO BLVD
Mailing Address - Street 2:SUITE #15
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-2582
Mailing Address - Country:US
Mailing Address - Phone:650-355-1133
Mailing Address - Fax:650-355-1133
Practice Address - Street 1:1750 FRANCISCO BLVD
Practice Address - Street 2:STE. 15
Practice Address - City:PACIFICA
Practice Address - State:CA
Practice Address - Zip Code:94044-2582
Practice Address - Country:US
Practice Address - Phone:650-355-1133
Practice Address - Fax:650-355-1133
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40618106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist