Provider Demographics
NPI:1144066580
Name:SULLIVAN, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
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 1:1327 BARTON AVE
Mailing Address - Street 2:
Mailing Address - City:POINT PLEASANT BORO
Mailing Address - State:NJ
Mailing Address - Zip Code:08742-4272
Mailing Address - Country:US
Mailing Address - Phone:732-456-2242
Mailing Address - Fax:
Practice Address - Street 1:63 W MAIN ST
Practice Address - Street 2:
Practice Address - City:FREEHOLD
Practice Address - State:NJ
Practice Address - Zip Code:07728-2140
Practice Address - Country:US
Practice Address - Phone:347-948-6402
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-04
Last Update Date:2024-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00800800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health