Provider Demographics
NPI:1578022430
Name:SULLIVAN, KATIE
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
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 1:8762 LOUISIANA ST STE J
Mailing Address - Street 2:
Mailing Address - City:MERRILLVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46410-7190
Mailing Address - Country:US
Mailing Address - Phone:219-472-0628
Mailing Address - Fax:219-750-9287
Practice Address - Street 1:8762 LOUISIANA ST STE J
Practice Address - Street 2:
Practice Address - City:MERRILLVILLE
Practice Address - State:IN
Practice Address - Zip Code:46410-7190
Practice Address - Country:US
Practice Address - Phone:219-472-0628
Practice Address - Fax:219-750-9287
Is Sole Proprietor?:No
Enumeration Date:2019-03-19
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician