Provider Demographics
NPI:1912212796
Name:SULLIVAN, KRISTA MARIE
Entity Type:Individual
Prefix:
First Name:KRISTA
Middle Name:MARIE
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 1:15 THOMAS ST
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:NY
Mailing Address - Zip Code:12865-9710
Mailing Address - Country:US
Mailing Address - Phone:518-321-0777
Mailing Address - Fax:
Practice Address - Street 1:15 W MAIN ST
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:NY
Practice Address - Zip Code:12816-1168
Practice Address - Country:US
Practice Address - Phone:518-321-0777
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-17
Last Update Date:2010-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225600000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDance Therapist