Provider Demographics
NPI:1124396163
Name:SULLIVAN, WILLIAM JAMES (ATC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JAMES
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 E SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:DURAND
Mailing Address - State:IL
Mailing Address - Zip Code:61024-9674
Mailing Address - Country:US
Mailing Address - Phone:815-222-6285
Mailing Address - Fax:
Practice Address - Street 1:18660 GRAPHIC DR
Practice Address - Street 2:
Practice Address - City:TINLEY PARK
Practice Address - State:IL
Practice Address - Zip Code:60477-6257
Practice Address - Country:US
Practice Address - Phone:708-686-1100
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-12-05
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL096.0031962255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer