| National Provider Identifier [NPI]: | 1053653840 |
| Last Name Of The Provider | SULLIVAN |
| First Name Of The Provider | KEESHA |
| Middle Initial Of The Provider | M |
| Credentials Of The Provider | LCSW |
| Gender Of The Provider | F |
| Entity Type Of The Provider | I |
| Street Address 1 Of The Provider | 4100 W KENNEDY BLVD |
| Street Address 2 Of The Provider | SUITE 327 |
| City Of The Provider | TAMPA |
| Zip Code Of The Provider | 336092288 |
| State Code Of The Provider | FL |
| Country Code Of The Provider | US |
| Provider Type Of The Provider | Licensed Clinical Social Worker |
| Medicare Participation Indicator | Y |
| Number Of HCPCS | 5 |
| Number Of Services | 139 |
| Number Of Medicare Beneficiaries | 24 |
| Total Submitted Charge Amount | 15582.34 |
| Total Medicare Allowed Amount | 8567.62 |
| Total Medicare Payment Amount | 5621.65 |
| Total Medicare Standardized Payment Amount | 5572.65 |
| Drug Suppress Indicator | |
| Number Of HCPCS Associated With Drug Services | 0 |
| Number Of Drug Services | 0 |
| Number Of Medicare Beneficiaries With Drug Services | 0 |
| Total Drug Submitted ChargeAmount | 0 |
| Total Drug Medicare AllowedAmount | 0 |
| Total Drug Medicare PaymentAmount | 0 |
| Total Drug Medicare Standardized Payment Amount | 0 |
| Medical SuppressIndicator | |
| Number Of HCPCS Associated With MedicalServices | 5 |
| Number Of Medical Services | 139 |
| Number Of Medicare Beneficiaries With Medical Services | 24 |
| Total Medical Submitted Charge Amount | 15582.34 |
| Total Medical Medicare Allowed Amount | 8567.62 |
| Total Medical Medicare Payment Amount | 5621.65 |
| Total Medical Medicare Standardized Payment Amount | 5572.65 |
| Average Age Of Beneficiaries | 63 |
| Number Of Beneficiaries Age Less65 | 11 |
| Number Of Beneficiaries Age 65 to 74 | |
| Number Of Beneficiaries Age 75 to 84 | |
| Number Of Beneficiaries Age Greater 84 | 0 |
| Number Of Female Beneficiaries | 11 |
| Number Of Male Beneficiaries | 13 |
| Number Of Non Hispanic White Beneficiaries | |
| Number Of Black or African American Beneficiaries | |
| Number Of AsianPacific Islander Beneficiaries | |
| Number Of Hispanic Beneficiaries | |
| Number Of American Indian Alaska Native Beneficiaries | |
| Number Of Beneficiaries With Race Not Else where Classified | |
| Number Of Beneficiaries With Medicare Only Entitlement | |
| Number Of Beneficiaries With Medicare Medicaid Entitlement | |
| Percent Of With Atrial Fibrillation | 0 |
| Percent Of With Alzheimers Disease or Dementia | 46 |
| Percent Of With Asthma | |
| Percent Of With Cancer | |
| Percent Of With Heart Failure | |
| Percent Of With Chronic Kidney Disease | 50 |
| Percent Of With Chronic Obstructive Pulmonary Disease | 46 |
| Percent Of With Depression | 75 |
| Percent Of With Diabetes | 54 |
| Percent Of With Hyperlipidemia | |
| Percent Of With Hypertension | 75 |
| Percent Of With Ischemic Heart Disease | 58 |
| Percent Of With Osteoporosis | |
| Percent Of With Rheumatoid Arthritis Osteoarthritis | |
| Percent Of With Schizophrenia Other PsychoticDisorders | 46 |
| Percent Of With Stroke | |
| Average HCC Risk Score Of Beneficiaries | 3.5087 |