Provider Demographics
NPI:1003040858
Name:SULLIVAN, MICHELLE YVETTE (DPT)
Entity Type:Individual
Prefix:DR
First Name:MICHELLE
Middle Name:YVETTE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:288 ATCHISON ST
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91104-1002
Mailing Address - Country:US
Mailing Address - Phone:626-798-4050
Mailing Address - Fax:626-798-4050
Practice Address - Street 1:288 ATCHISON ST
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91104-1002
Practice Address - Country:US
Practice Address - Phone:626-798-4050
Practice Address - Fax:626-798-4050
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-08
Last Update Date:2009-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT27523174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist