Provider Demographics
NPI:1871953596
Name:SULLIVAN, LAURA LYNN (MFT)
Entity type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:LYNN
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 1:530 PLAZA DR STE 130
Mailing Address - Street 2:
Mailing Address - City:FOLSOM
Mailing Address - State:CA
Mailing Address - Zip Code:95630-4782
Mailing Address - Country:US
Mailing Address - Phone:916-742-2984
Mailing Address - Fax:
Practice Address - Street 1:530 PLAZA DR STE 130
Practice Address - Street 2:
Practice Address - City:FOLSOM
Practice Address - State:CA
Practice Address - Zip Code:95630-4782
Practice Address - Country:US
Practice Address - Phone:916-742-2984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-02-24
Last Update Date:2017-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA98861106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist