Provider Demographics
NPI:1497003230
Name:SULLIVAN, KRISTEN (PHD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S WELLS RD STE 200
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1377
Mailing Address - Country:US
Mailing Address - Phone:805-659-1740
Mailing Address - Fax:
Practice Address - Street 1:200 S WELLS RD STE 200
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93004-1377
Practice Address - Country:US
Practice Address - Phone:805-659-1740
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-28
Last Update Date:2013-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY25840103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist