Healthcare Provider Details

I. General information

NPI: 1497034938
Provider Name (Legal Business Name): KIMBERLY SULLIVAN PSY.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2011
Last Update Date: 07/24/2020
Certification Date: 07/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

650 E INDIAN SCHOOL RD
PHOENIX AZ
85012-1839
US

IV. Provider business mailing address

2727 E SHANNON ST
GILBERT AZ
85295-5190
US

V. Phone/Fax

Practice location:
  • Phone: 602-277-5551
  • Fax:
Mailing address:
  • Phone: 480-686-4507
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberPSY-004332
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: