Provider Demographics
NPI:1578948295
Name:SULLIVAN, KERI
Entity Type:Individual
Prefix:
First Name:KERI
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 1:8303 SPOTTER DR
Mailing Address - Street 2:
Mailing Address - City:APEX
Mailing Address - State:NC
Mailing Address - Zip Code:27502-2458
Mailing Address - Country:US
Mailing Address - Phone:315-447-3617
Mailing Address - Fax:
Practice Address - Street 1:175 MIDDLE ST
Practice Address - Street 2:SUITE 1201
Practice Address - City:LAKE MARY
Practice Address - State:FL
Practice Address - Zip Code:32746-3625
Practice Address - Country:US
Practice Address - Phone:315-447-3617
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-23
Last Update Date:2017-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11518907103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL009093700Medicaid