Provider Demographics
NPI:1609541960
Name:SULLIVAN, KRISTINA
Entity Type:Individual
Prefix:
First Name:KRISTINA
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 1:88 HALF MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06890-3032
Mailing Address - Country:US
Mailing Address - Phone:203-450-2391
Mailing Address - Fax:
Practice Address - Street 1:88 HALF MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:CT
Practice Address - Zip Code:06890-3032
Practice Address - Country:US
Practice Address - Phone:704-779-3503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-10
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical