Provider Demographics
NPI:1558665224
Name:SULLIVAN, TIFFANY L (LMFT)
Entity type:Individual
Prefix:
First Name:TIFFANY
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:TIFFANY
Other - Middle Name:L
Other - Last Name:PARDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:711 JEFFERSON ST STE 203
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-5556
Mailing Address - Country:US
Mailing Address - Phone:707-514-0460
Mailing Address - Fax:
Practice Address - Street 1:955 SORTER DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-7974
Practice Address - Country:US
Practice Address - Phone:707-301-0158
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-10
Last Update Date:2024-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAIMF65669101YM0800X, 106H00000X
CA99784101YM0800X, 106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health