Provider Demographics
NPI:1508517327
Name:SULLIVAN, KATHIE JEAN (LCSW)
Entity Type:Individual
Prefix:
First Name:KATHIE
Middle Name:JEAN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:KASSIE
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:14958 VISTARIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75248-5562
Mailing Address - Country:US
Mailing Address - Phone:307-272-7560
Mailing Address - Fax:
Practice Address - Street 1:14958 VISTARIDGE DR
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75248-5562
Practice Address - Country:US
Practice Address - Phone:307-272-7560
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-13
Last Update Date:2022-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO099232081041C0700X
MT69051041C0700X
TX1068621041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical