Provider Demographics
NPI:1003172438
Name:SULLIVAN, BRIAN KEITH (MT)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:396 STARBRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MURRAYVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30564-2817
Mailing Address - Country:US
Mailing Address - Phone:706-265-9530
Mailing Address - Fax:706-867-7969
Practice Address - Street 1:326 STARBRIDGE RD
Practice Address - Street 2:
Practice Address - City:MURRAYVILLE
Practice Address - State:GA
Practice Address - Zip Code:30564-2817
Practice Address - Country:US
Practice Address - Phone:706-265-9530
Practice Address - Fax:706-867-7969
Is Sole Proprietor?:Yes
Enumeration Date:2012-04-10
Last Update Date:2012-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT005008225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist