Provider Demographics
NPI:1598020398
Name:SULLIVAN, KRISTI SPENCE (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTI
Middle Name:SPENCE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2175 MEDFIELD TRL NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-3009
Mailing Address - Country:US
Mailing Address - Phone:404-452-3101
Mailing Address - Fax:
Practice Address - Street 1:2175 MEDFIELD TRL NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30345-3009
Practice Address - Country:US
Practice Address - Phone:404-452-3101
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-08
Last Update Date:2012-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW0038841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical