Provider Demographics
NPI:1174223879
Name:CROSSLEY SULLIVAN, KABBIEAN
Entity type:Individual
Prefix:
First Name:KABBIEAN
Middle Name:
Last Name:CROSSLEY SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6105 NW CASTLEBAY LN
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34983-4132
Mailing Address - Country:US
Mailing Address - Phone:702-931-4251
Mailing Address - Fax:
Practice Address - Street 1:13195 SW 134TH ST STE 201
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33186-4585
Practice Address - Country:US
Practice Address - Phone:786-206-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-09
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL-23-259572106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician