Provider Demographics
NPI:1932256302
Name:SULLIVAN, KENNETH P (PHD)
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:P
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1104 GLENEAGLES DR SW # B
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35801-6404
Mailing Address - Country:US
Mailing Address - Phone:256-880-8202
Mailing Address - Fax:256-880-8234
Practice Address - Street 1:1104 GLENEAGLES DR SW # B
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35801-6404
Practice Address - Country:US
Practice Address - Phone:256-880-8202
Practice Address - Fax:256-880-8234
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL413103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL000070874Medicaid
AL117581Medicare UPIN
AL184585Medicare UPIN
AL70874SULMedicare ID - Type Unspecified
AL515-22394Medicare UPIN
AL51070874Medicare UPIN