Provider Demographics
NPI:1376653964
Name:SULLIVAN, MARIA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MARIA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1520 PURPLE MARTIN TRCE
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9343
Mailing Address - Country:US
Mailing Address - Phone:770-886-1332
Mailing Address - Fax:
Practice Address - Street 1:540 LAKE CENTER PKWY
Practice Address - Street 2:SUITE 107
Practice Address - City:CUMMING
Practice Address - State:GA
Practice Address - Zip Code:30040-7727
Practice Address - Country:US
Practice Address - Phone:770-205-3939
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAPTA001177OtherLICENSE#