Provider Demographics
NPI:1790938694
Name:SULLIVAN, KATHLEEN SCARLETT (MFT)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:SCARLETT
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 132
Mailing Address - Street 2:
Mailing Address - City:CEDAR RIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:95924-0132
Mailing Address - Country:US
Mailing Address - Phone:530-265-1720
Mailing Address - Fax:
Practice Address - Street 1:500 CROWN POINT CIR STE 120
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-9561
Practice Address - Country:US
Practice Address - Phone:530-265-1720
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-23
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49153106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist