Provider Demographics
NPI:1073269320
Name:SULLIVAN, GERROMI (BS, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:GERROMI
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:BS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6110 BREEZEWOOD DR APT 104
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-4148
Mailing Address - Country:US
Mailing Address - Phone:240-602-6626
Mailing Address - Fax:
Practice Address - Street 1:1801 TURKEY POINT RD
Practice Address - Street 2:
Practice Address - City:ESSEX
Practice Address - State:MD
Practice Address - Zip Code:21221-1734
Practice Address - Country:US
Practice Address - Phone:240-602-6626
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-24
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00011602255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer