Provider Demographics
NPI:1346097607
Name:SULLIVAN, KERRY (LSW LCADC ICGC-1)
Entity type:Individual
Prefix:MRS
First Name:KERRY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LSW LCADC ICGC-1
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 E REVERE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:08225-2436
Mailing Address - Country:US
Mailing Address - Phone:609-513-2875
Mailing Address - Fax:
Practice Address - Street 1:536 MAPLE AVE
Practice Address - Street 2:
Practice Address - City:LINWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08221-1213
Practice Address - Country:US
Practice Address - Phone:609-517-0423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-03
Last Update Date:2024-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ44SL06785900104100000X
NJ37L00351100101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)