Provider Demographics
NPI:1306865845
Name:SULLIVAN, KATHLEEN ANN (AUD)
Entity Type:Individual
Prefix:DR
First Name:KATHLEEN
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12927 SLEEPY WIND ST
Mailing Address - Street 2:
Mailing Address - City:MOORPARK
Mailing Address - State:CA
Mailing Address - Zip Code:93021-2935
Mailing Address - Country:US
Mailing Address - Phone:310-989-3092
Mailing Address - Fax:805-530-3989
Practice Address - Street 1:1820 MARRON RD
Practice Address - Street 2:STE. 102
Practice Address - City:CARLSBAD
Practice Address - State:CA
Practice Address - Zip Code:92008-1177
Practice Address - Country:US
Practice Address - Phone:760-434-0125
Practice Address - Fax:760-434-4531
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU752231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAU752Medicare PIN