Provider Demographics
NPI:1619930526
Name:SULLIVAN, KAREN LYNN
Entity Type:Individual
Prefix:DR
First Name:KAREN
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:KAREN
Other - Middle Name:LYNN
Other - Last Name:RUNDQUIST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PSYD
Mailing Address - Street 1:143 N MCCORMICK ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2723
Mailing Address - Country:US
Mailing Address - Phone:928-717-0521
Mailing Address - Fax:928-778-3464
Practice Address - Street 1:143 N MCCORMICK ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2723
Practice Address - Country:US
Practice Address - Phone:928-717-0521
Practice Address - Fax:928-778-3464
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3309103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZR54215Medicare UPIN
AZ28852Medicare ID - Type Unspecified