Provider Demographics
NPI:1831609809
Name:SULLIVAN, KIM (MA, LPC, RPT, NCC)
Entity type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA, LPC, RPT, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10A CHISHOLM TRL
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-5043
Mailing Address - Country:US
Mailing Address - Phone:929-352-7529
Mailing Address - Fax:737-443-6081
Practice Address - Street 1:10A CHISHOLM TRL
Practice Address - Street 2:
Practice Address - City:ROUND ROCK
Practice Address - State:TX
Practice Address - Zip Code:78681
Practice Address - Country:US
Practice Address - Phone:929-352-7529
Practice Address - Fax:737-443-6081
Is Sole Proprietor?:No
Enumeration Date:2017-10-04
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX74561101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX01-3803413Medicaid