Provider Demographics
NPI:1982140893
Name:SULLIVAN, MARY KATHLEEN (MA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHLEEN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA
Other - Prefix:
Other - First Name:KATE
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MA
Mailing Address - Street 1:PO BOX 1077
Mailing Address - Street 2:
Mailing Address - City:KELSO
Mailing Address - State:WA
Mailing Address - Zip Code:98626-0111
Mailing Address - Country:US
Mailing Address - Phone:360-577-7442
Mailing Address - Fax:360-577-7904
Practice Address - Street 1:309 OAK ST
Practice Address - Street 2:
Practice Address - City:KELSO
Practice Address - State:WA
Practice Address - Zip Code:98626-2340
Practice Address - Country:US
Practice Address - Phone:360-577-7442
Practice Address - Fax:360-577-7904
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2017-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACG 60673859101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health