Provider Demographics
NPI:1386830537
Name:SULLIVAN, KELLY J (PHD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 5TH ST APT 3
Mailing Address - Street 2:
Mailing Address - City:HOBOKEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07030-4964
Mailing Address - Country:US
Mailing Address - Phone:917-453-9377
Mailing Address - Fax:
Practice Address - Street 1:86 HUDSON ST
Practice Address - Street 2:UNIT 3A
Practice Address - City:HOBOKEN
Practice Address - State:NJ
Practice Address - Zip Code:07030-5617
Practice Address - Country:US
Practice Address - Phone:917-453-9377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-21
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017207103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical