Provider Demographics
NPI:1174008312
Name:SULLIVAN, MEGAN KELLY
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:KELLY
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 POND ST
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:MA
Mailing Address - Zip Code:01516-2029
Mailing Address - Country:US
Mailing Address - Phone:508-954-0998
Mailing Address - Fax:
Practice Address - Street 1:56 POND ST
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:MA
Practice Address - Zip Code:01516-2029
Practice Address - Country:US
Practice Address - Phone:508-954-0998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-02
Last Update Date:2018-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer