Provider Demographics
NPI:1124252077
Name:SULTAN, KELLY ANN ANTISTA
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:ANN ANTISTA
Last Name:SULTAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KELLY
Other - Middle Name:ANN
Other - Last Name:ANTISTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1828 FIXLINI ST.
Mailing Address - Street 2:APT B
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401
Mailing Address - Country:US
Mailing Address - Phone:805-602-0733
Mailing Address - Fax:
Practice Address - Street 1:3765 S HIGUERA ST
Practice Address - Street 2:STE 100
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-1570
Practice Address - Country:US
Practice Address - Phone:805-781-3535
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2015-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health