Provider Demographics
NPI:1386724961
Name:SULLIVAN, KERRY RENEE (LMHC, RPT)
Entity type:Individual
Prefix:MS
First Name:KERRY
Middle Name:RENEE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMHC, RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2021 W 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WATERLOO
Mailing Address - State:IA
Mailing Address - Zip Code:50702-3354
Mailing Address - Country:US
Mailing Address - Phone:319-529-9929
Mailing Address - Fax:888-981-5029
Practice Address - Street 1:978 HOME PLZ
Practice Address - Street 2:SUITE 300
Practice Address - City:WATERLOO
Practice Address - State:IA
Practice Address - Zip Code:50701-4809
Practice Address - Country:US
Practice Address - Phone:319-529-9929
Practice Address - Fax:319-981-5029
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2014-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA874101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health