Provider Demographics
NPI:1467786004
Name:SULLIVAN, KELLY L
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:L
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 1:79 AZALEA DR
Mailing Address - Street 2:
Mailing Address - City:HARWICH
Mailing Address - State:MA
Mailing Address - Zip Code:02645-1723
Mailing Address - Country:US
Mailing Address - Phone:774-237-0017
Mailing Address - Fax:
Practice Address - Street 1:105 PARK ST
Practice Address - Street 2:
Practice Address - City:HYANNIS
Practice Address - State:MA
Practice Address - Zip Code:02601-5205
Practice Address - Country:US
Practice Address - Phone:508-771-9599
Practice Address - Fax:508-771-1986
Is Sole Proprietor?:No
Enumeration Date:2009-09-30
Last Update Date:2009-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical