Provider Demographics
NPI:1033224910
Name:SULLIVAN, NEELY TOLBERT (PT)
Entity Type:Individual
Prefix:
First Name:NEELY
Middle Name:TOLBERT
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:NEELY
Other - Middle Name:
Other - Last Name:TOLBERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PT
Mailing Address - Street 1:8823 PRODUCTION LN
Mailing Address - Street 2:
Mailing Address - City:OOLTEWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37363-6511
Mailing Address - Country:US
Mailing Address - Phone:423-238-7217
Mailing Address - Fax:423-238-3473
Practice Address - Street 1:1025 E WEST CONNECTOR # 4
Practice Address - Street 2:SUITE 406
Practice Address - City:AUSTELL
Practice Address - State:GA
Practice Address - Zip Code:30106-8513
Practice Address - Country:US
Practice Address - Phone:770-384-1001
Practice Address - Fax:770-384-0333
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2011-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPT8785225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP4895Medicare ID - Type UnspecifiedGROUP NUMBER
GA65BBDSJMedicare ID - Type Unspecified