Provider Demographics
NPI:1275878183
Name:SULLIVAN, AMANDA J (PTA)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:AMANDA
Other - Middle Name:J
Other - Last Name:KADE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PTA
Mailing Address - Street 1:71 MILLARD RD
Mailing Address - Street 2:
Mailing Address - City:NORTH ATTLEBORO
Mailing Address - State:MA
Mailing Address - Zip Code:02760-4407
Mailing Address - Country:US
Mailing Address - Phone:508-838-4090
Mailing Address - Fax:
Practice Address - Street 1:71 MILLARD RD
Practice Address - Street 2:
Practice Address - City:NORTH ATTLEBORO
Practice Address - State:MA
Practice Address - Zip Code:02760-4407
Practice Address - Country:US
Practice Address - Phone:508-838-4090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-04
Last Update Date:2012-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI00727225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant