Provider Demographics
NPI:1831636778
Name:SULLIVAN, KELLY
Entity Type:Individual
Prefix:
First Name:KELLY
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 1:273 POWELL CIR
Mailing Address - Street 2:
Mailing Address - City:BERLIN
Mailing Address - State:MD
Mailing Address - Zip Code:21811-1185
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:273 POWELL CIR
Practice Address - Street 2:
Practice Address - City:BERLIN
Practice Address - State:MD
Practice Address - Zip Code:21811-1185
Practice Address - Country:US
Practice Address - Phone:443-783-9391
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-30
Last Update Date:2017-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst