Provider Information for 1275069577
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CORY RAYMOND SULLIVAN ASW
Sex: Male
NPI: 1275069577
Last Updated: 2023-07-05
Certification Date: 2023-06-22
Certification Date: 2023-06-22
Details
| Name | Value | ||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| NPI | 1275069577 | ||||||||||||||||
| Enumeration Date | 2017-05-04 | ||||||||||||||||
| NPI Type | NPI-1 Individual | ||||||||||||||||
| Sole Proprietor | NO | ||||||||||||||||
| Status | Active | ||||||||||||||||
| Mailing Address | 2008 N GAREY AVE POMONA, CA 91767-2722 United States Phone: 909-623-6131 | Fax: | ||||||||||||||||
| Primary Practice Address | 2008 N GAREY AVE POMONA, CA 91767-2722 United States Phone: 909-623-6131 | Fax: | ||||||||||||||||
| Secondary Practice Address(es) | 1149 S HILL ST | ||||||||||||||||
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