Provider Demographics
NPI:1114478898
Name:SULLIVAN, KAITLIN ROSE (BCABA)
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:ROSE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:BCABA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7820 N 13TH ST
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33604-3230
Mailing Address - Country:US
Mailing Address - Phone:734-476-6187
Mailing Address - Fax:
Practice Address - Street 1:7820 N 13TH ST
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33604-3230
Practice Address - Country:US
Practice Address - Phone:734-476-6187
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-18
Last Update Date:2018-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1-16-23982103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst