Provider Demographics
NPI:1376727909
Name:SULLIVAN, MICHELLE LYN (MSPT)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:LYN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:
Other - Last Name:GEORGE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:292 COMMERCE AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTHERN PINES
Mailing Address - State:NC
Mailing Address - Zip Code:28387-7059
Mailing Address - Country:US
Mailing Address - Phone:910-757-0408
Mailing Address - Fax:910-757-0413
Practice Address - Street 1:292 COMMERCE AVE
Practice Address - Street 2:
Practice Address - City:SOUTHERN PINES
Practice Address - State:NC
Practice Address - Zip Code:28387-7059
Practice Address - Country:US
Practice Address - Phone:910-757-0408
Practice Address - Fax:910-757-0413
Is Sole Proprietor?:No
Enumeration Date:2007-12-18
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEPT2584225100000X
ME218905225100000X
NCP19629225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist