Provider Demographics
NPI:1407075989
Name:SULLIVAN, KELLI ANN (LICSW)
Entity Type:Individual
Prefix:MRS
First Name:KELLI
Middle Name:ANN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LICSW
Other - Prefix:
Other - First Name:KELLI
Other - Middle Name:ANN
Other - Last Name:BACKSTROM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LICSW
Mailing Address - Street 1:37 CENTRAL ST
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:MA
Mailing Address - Zip Code:01949-1716
Mailing Address - Country:US
Mailing Address - Phone:978-223-3272
Mailing Address - Fax:
Practice Address - Street 1:37 CENTRAL ST
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:MA
Practice Address - Zip Code:01949-1716
Practice Address - Country:US
Practice Address - Phone:978-223-3272
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2021-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA114135101YM0800X
1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Single Specialty