Provider Demographics
NPI:1053653840
Name:SULLIVAN, KEESHA MONAIE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:KEESHA
Middle Name:MONAIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8450 112TH ST.
Mailing Address - Street 2:UNIT 104
Mailing Address - City:SEMINOLE
Mailing Address - State:FL
Mailing Address - Zip Code:33772-4221
Mailing Address - Country:US
Mailing Address - Phone:727-692-7364
Mailing Address - Fax:
Practice Address - Street 1:4100 W KENNEDY BLVD
Practice Address - Street 2:SUITE 327
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-2288
Practice Address - Country:US
Practice Address - Phone:727-692-7364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-20
Last Update Date:2013-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLSW112271041C0700X
NY0704941041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical