Provider Demographics
NPI:1457508996
Name:SULLIVAN, KEVIN A (LISW)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:A
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LISW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1532 W. MAIN ST.
Mailing Address - Street 2:STE. 100
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WA
Mailing Address - Zip Code:53590
Mailing Address - Country:US
Mailing Address - Phone:608-825-7226
Mailing Address - Fax:
Practice Address - Street 1:1500 W. MAIN ST. STE 300
Practice Address - Street 2:PHOENIX COUNSELING
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590
Practice Address - Country:US
Practice Address - Phone:608-825-6711
Practice Address - Fax:608-834-6499
Is Sole Proprietor?:No
Enumeration Date:2008-08-27
Last Update Date:2008-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI328101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39-728100Medicaid