Provider Demographics
NPI:1164565263
Name:SULLIVAN, DANIEL J (PT, CFP)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT, CFP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:34 HENNESSEY AVENUE
Mailing Address - Street 2:
Mailing Address - City:BRUNSWICK
Mailing Address - State:ME
Mailing Address - Zip Code:04011
Mailing Address - Country:US
Mailing Address - Phone:207-725-7578
Mailing Address - Fax:207-725-7549
Practice Address - Street 1:34 HENNESSEY AVENUE
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-0000
Practice Address - Country:US
Practice Address - Phone:207-725-7578
Practice Address - Fax:207-725-7549
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2013-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME225100000X225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME039097OtherANTHEM/BCBS
ME281020099Medicaid
MM8408Medicare PIN