Provider Demographics
NPI:1700762754
Name:SULLIVAN, KATHERINE KELLY
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:KELLY
Last Name:SULLIVAN
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 HAWTHORNE RD
Mailing Address - Street 2:
Mailing Address - City:ESSEX FELLS
Mailing Address - State:NJ
Mailing Address - Zip Code:07021-1411
Mailing Address - Country:US
Mailing Address - Phone:973-865-4648
Mailing Address - Fax:
Practice Address - Street 1:222 MOUNT AIRY RD
Practice Address - Street 2:
Practice Address - City:BASKING RIDGE
Practice Address - State:NJ
Practice Address - Zip Code:07920-2335
Practice Address - Country:US
Practice Address - Phone:908-350-9143
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-08-14
Last Update Date:2025-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00900800101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health