Provider Demographics
NPI:1831781624
Name:SULLIVAN, KRISTY BASCLE
Entity type:Individual
Prefix:MRS
First Name:KRISTY
Middle Name:BASCLE
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 1:2351 VILLERE ST
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70448-5146
Mailing Address - Country:US
Mailing Address - Phone:985-869-0306
Mailing Address - Fax:
Practice Address - Street 1:2810 E CAUSEWAY APPROACH
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70448-3502
Practice Address - Country:US
Practice Address - Phone:985-869-0306
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA117172052084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry