Provider Demographics
NPI:1144370065
Name:SULLIVAN, KELLY G
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:G
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:G
Other - Last Name:SCHNEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:444 W KENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40214-2859
Mailing Address - Country:US
Mailing Address - Phone:502-396-1472
Mailing Address - Fax:888-456-3844
Practice Address - Street 1:444 W KENWOOD DR
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40214-2859
Practice Address - Country:US
Practice Address - Phone:502-396-1472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYKY-R2746225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics