Provider Demographics
NPI:1235476763
Name:SULLIVAN, MISTY (MED)
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8206 HIGHVIEW CT
Mailing Address - Street 2:
Mailing Address - City:CRESTWOOD
Mailing Address - State:KY
Mailing Address - Zip Code:40014-8105
Mailing Address - Country:US
Mailing Address - Phone:502-794-2965
Mailing Address - Fax:
Practice Address - Street 1:1512 BAXTER AVE
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40205-1009
Practice Address - Country:US
Practice Address - Phone:502-262-2887
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-01-03
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY166372103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical