Provider Demographics
NPI:1215585112
Name:SULLIVAN, TIMOTHY II (LMT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:SULLIVAN
Suffix:II
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:318 E MAIDEN ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-5108
Mailing Address - Country:US
Mailing Address - Phone:724-993-4615
Mailing Address - Fax:
Practice Address - Street 1:318 E MAIDEN ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:PA
Practice Address - Zip Code:15301-5108
Practice Address - Country:US
Practice Address - Phone:724-993-4615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-04
Last Update Date:2019-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMSG011511225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist