Provider Demographics
NPI:1114334604
Name:SULLIVAN, KATHERINE (PHD, ATC, USAW)
Entity Type:Individual
Prefix:DR
First Name:KATHERINE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD, ATC, USAW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:656 W KIRBY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-3622
Mailing Address - Country:US
Mailing Address - Phone:313-577-9326
Mailing Address - Fax:
Practice Address - Street 1:656 W KIRBY ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-3622
Practice Address - Country:US
Practice Address - Phone:313-577-9326
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-16
Last Update Date:2024-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-40542255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer