Provider Demographics
NPI:1225275746
Name:SULLIVAN, KIMBERLY ANN (LMFT)
Entity Type:Individual
Prefix:MS
First Name:KIMBERLY
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9008 ELK GROVE BLVD # 20
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95624-1945
Mailing Address - Country:US
Mailing Address - Phone:916-709-1648
Mailing Address - Fax:916-688-3997
Practice Address - Street 1:9008 ELK GROVE BLVD # 20
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95624
Practice Address - Country:US
Practice Address - Phone:916-709-1648
Practice Address - Fax:916-688-3997
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-21
Last Update Date:2021-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALMFT45203106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1225275746Medicaid