Provider Demographics
NPI:1437663713
Name:SULLIVAN, KIM LERNER
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:LERNER
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1926 VIA CTR STE B
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6056
Mailing Address - Country:US
Mailing Address - Phone:760-294-1206
Mailing Address - Fax:
Practice Address - Street 1:5762 BOLSA AVE STE 100
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92649-1172
Practice Address - Country:US
Practice Address - Phone:714-292-2322
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-26
Last Update Date:2024-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARBT-16-26762106S00000X
CA1-1934539103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician