Provider Demographics
NPI:1205625795
Name:SULLIVAN, KELLY ANN
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN
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 1:165 VILLAGE CIRCLE WAY APT 16
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:NH
Mailing Address - Zip Code:03102-7114
Mailing Address - Country:US
Mailing Address - Phone:617-378-5783
Mailing Address - Fax:
Practice Address - Street 1:165 VILLAGE CIRCLE WAY APT 16
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03102-7114
Practice Address - Country:US
Practice Address - Phone:617-378-5783
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHNA103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical