Provider Demographics
NPI:1063024792
Name:SULLIVAN, TIMOTHY
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 E ELM ST APT 1203
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36081-3498
Mailing Address - Country:US
Mailing Address - Phone:205-790-2452
Mailing Address - Fax:
Practice Address - Street 1:601 E ELM ST APT 1203
Practice Address - Street 2:
Practice Address - City:TROY
Practice Address - State:AL
Practice Address - Zip Code:36081-3498
Practice Address - Country:US
Practice Address - Phone:205-790-2452
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer