Provider Demographics
NPI:1316585763
Name:SULLIVAN, KIMBERLY
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KIMBERLY
Other - Middle Name:
Other - Last Name:DISMUKES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5025 HADLEY MEADOW CT
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89131-5211
Mailing Address - Country:US
Mailing Address - Phone:773-600-7091
Mailing Address - Fax:
Practice Address - Street 1:5025 HADLEY MEADOW CT
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89131-5211
Practice Address - Country:US
Practice Address - Phone:773-600-7091
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-17
Last Update Date:2024-04-01
Deactivation Date:2024-01-10
Deactivation Code:
Reactivation Date:2024-04-01
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician