Provider Demographics
NPI:1700776317
Name:SULLIVAN, KATHRYN HALEY (NC LMBT)
Entity type:Individual
Prefix:MS
First Name:KATHRYN
Middle Name:HALEY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:NC LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:49 SPINDRIFT TRL
Mailing Address - Street 2:
Mailing Address - City:KITTY HAWK
Mailing Address - State:NC
Mailing Address - Zip Code:27949-3725
Mailing Address - Country:US
Mailing Address - Phone:252-341-3401
Mailing Address - Fax:
Practice Address - Street 1:12 JUNIPER TRL STE 101
Practice Address - Street 2:
Practice Address - City:KITTY HAWK
Practice Address - State:NC
Practice Address - Zip Code:27949-3475
Practice Address - Country:US
Practice Address - Phone:252-341-3401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-07
Last Update Date:2025-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC12309225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist