Provider Demographics
NPI:1922202795
Name:SULLIVAN, KATHLEEN SUE (LMP)
Entity Type:Individual
Prefix:MS
First Name:KATHLEEN
Middle Name:SUE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10116 NE 187TH ST
Mailing Address - Street 2:
Mailing Address - City:BOTHELL
Mailing Address - State:WA
Mailing Address - Zip Code:98011-3845
Mailing Address - Country:US
Mailing Address - Phone:206-409-8782
Mailing Address - Fax:425-877-1953
Practice Address - Street 1:10116 NE 187TH ST
Practice Address - Street 2:
Practice Address - City:BOTHELL
Practice Address - State:WA
Practice Address - Zip Code:98011-3845
Practice Address - Country:US
Practice Address - Phone:206-409-8782
Practice Address - Fax:425-877-1953
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-13
Last Update Date:2021-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00012330225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist