Provider Demographics
NPI:1497244511
Name:SULLIVAN, KIMBERLY PAIGE (LMSW)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:PAIGE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:616 N HIGHLAND AVE NE APT 4A
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30306-4548
Mailing Address - Country:US
Mailing Address - Phone:423-503-8633
Mailing Address - Fax:
Practice Address - Street 1:445 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-1707
Practice Address - Country:US
Practice Address - Phone:404-508-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-03
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMSW008007104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker