Provider Demographics
NPI:1376072967
Name:SULLIVAN, CARLY RENEE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:CARLY
Middle Name:RENEE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:33900 HARPER AVE STE 104
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-4258
Mailing Address - Country:US
Mailing Address - Phone:586-350-2644
Mailing Address - Fax:586-547-3735
Practice Address - Street 1:2302 S DIXON RD STE 150
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6427
Practice Address - Country:US
Practice Address - Phone:765-416-6630
Practice Address - Fax:765-416-6629
Is Sole Proprietor?:No
Enumeration Date:2017-06-07
Last Update Date:2019-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05012453A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist