Provider Demographics
NPI:1437657202
Name:SULLIVAN, KENLEY (PSYD)
Entity Type:Individual
Prefix:
First Name:KENLEY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20789 NW 3RD CT
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-3519
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 N FEDERAL HWY STE 216
Practice Address - Street 2:
Practice Address - City:POMPANO BEACH
Practice Address - State:FL
Practice Address - Zip Code:33062-4328
Practice Address - Country:US
Practice Address - Phone:954-533-7705
Practice Address - Fax:954-533-7705
Is Sole Proprietor?:No
Enumeration Date:2018-01-26
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPY10013103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist