| Doctor Name: | DR. LAURA JEAN SULLIVAN |
| NPI Number: | 1184861882 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | PSY.D. |
| License Number: | PSY 22206 |
| Business Practice Address: | 100 Prison Rd Represa, CA - 956713000 |
| Business Phone Number: | 9169858610 |
| Business Fax Number: | |
| Mailing Address: | Po Box 6781, FOLSOM |
| State: | CA |
| Postal Code: | 957636781 |
| Phone Number: | 9169858610 |
| Fax Number: | |
| NPI Enumeration Date: | 01/16/2009 |
| NPI Last Update Date: | 01/16/2009 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 103TF0200X |
| License Number: | PSY 22206 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Behavioral Health & Social Service Providers |
| Taxonomy Classification: | Psychologist |
| Taxonomy Specialization: | Forensic |
| Taxonomy Definition: | |