Healthcare Provider Details

I. General information

NPI: 1740104132
Provider Name (Legal Business Name): KELLY LEE SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2730 E 3300 S
SALT LAKE CITY UT
84109-2819
US

IV. Provider business mailing address

2730 E 3300 S
SALT LAKE CITY UT
84109-2819
US

V. Phone/Fax

Practice location:
  • Phone: 801-487-0896
  • Fax:
Mailing address:
  • Phone: 801-487-0896
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number14302761-4003
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: