Healthcare Provider Details

I. General information

NPI: 1396062873
Provider Name (Legal Business Name): KEITH ALAN SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/23/2010
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4601 LAKE BOONE TRL STE 1B
RALEIGH NC
27607-7503
US

IV. Provider business mailing address

515 RICE CIR
WAKE FOREST NC
27587-2516
US

V. Phone/Fax

Practice location:
  • Phone: 919-781-1800
  • Fax:
Mailing address:
  • Phone: 919-426-1399
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number21226A
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: