Provider Demographics
NPI:1902498785
Name:SULLIVAN, KELLY COLLEEN (MA, PLMHP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:COLLEEN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MA, PLMHP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 SOMMERLYN RD APT 1003
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3406
Mailing Address - Country:US
Mailing Address - Phone:605-890-1812
Mailing Address - Fax:
Practice Address - Street 1:6180 LEHMAN DR
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-3444
Practice Address - Country:US
Practice Address - Phone:719-452-4803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-03
Last Update Date:2023-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0019198101Y00000X
NE12489101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional