Provider Demographics
NPI:1033496179
Name:SULLIVAN, SCOTT PATRIC (MHA,ATC, RKT)
Entity Type:Individual
Prefix:MR
First Name:SCOTT
Middle Name:PATRIC
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MHA,ATC, RKT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 RED MOUNTAIN DR
Mailing Address - Street 2:
Mailing Address - City:LONGMONT
Mailing Address - State:CO
Mailing Address - Zip Code:80504-2277
Mailing Address - Country:US
Mailing Address - Phone:303-684-9525
Mailing Address - Fax:303-774-7899
Practice Address - Street 1:205 S MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:LONGMONT
Practice Address - State:CO
Practice Address - Zip Code:80501-1716
Practice Address - Country:US
Practice Address - Phone:303-684-9525
Practice Address - Fax:303-774-7899
Is Sole Proprietor?:Yes
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6092255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer