Provider Demographics
NPI:1215572771
Name:SULLIVAN, KRISTINA (BCBA)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9202 WAYMOND AVE
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND
Mailing Address - State:IN
Mailing Address - Zip Code:46322-2521
Mailing Address - Country:US
Mailing Address - Phone:219-200-8135
Mailing Address - Fax:
Practice Address - Street 1:2906 HIGHWAY AVE
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1631
Practice Address - Country:US
Practice Address - Phone:311-219-5138
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-08
Last Update Date:2022-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INRBT-16-24535106S00000X
BCBA-1-22-60094103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician