Provider Demographics
NPI:1114294329
Name:SULLIVAN, SEAN DAVID (PTA/L)
Entity Type:Individual
Prefix:
First Name:SEAN
Middle Name:DAVID
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:42 BISCAYNE AVE
Mailing Address - Street 2:
Mailing Address - City:WEYMOUTH
Mailing Address - State:MA
Mailing Address - Zip Code:02188-3025
Mailing Address - Country:US
Mailing Address - Phone:781-682-9148
Mailing Address - Fax:
Practice Address - Street 1:804 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-3055
Practice Address - Country:US
Practice Address - Phone:508-583-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-17
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3586225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant