Provider Demographics
NPI:1790938694
Name:SULLIVAN, KATHLEEN SCARLETT (MFT)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SCARLETT
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 635212
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92163-5212
Mailing Address - Country:US
Mailing Address - Phone:619-542-4913
Mailing Address - Fax:
Practice Address - Street 1:3851 ROSECRANS ST STE K-08
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3115
Practice Address - Country:US
Practice Address - Phone:619-542-4913
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2020-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49153106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist