Provider Demographics
NPI:1851542096
Name:SULLIVAN, KRISTINE J (LCSW)
Entity Type:Individual
Prefix:
First Name:KRISTINE
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3105 S SARE RD APT 300
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47401-4378
Mailing Address - Country:US
Mailing Address - Phone:812-333-3939
Mailing Address - Fax:812-585-3802
Practice Address - Street 1:3105 S SARE RD APT 300
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-4378
Practice Address - Country:US
Practice Address - Phone:812-333-3939
Practice Address - Fax:812-585-3802
Is Sole Proprietor?:No
Enumeration Date:2008-10-07
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN34005593A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN940070G1Medicare PIN