Provider Demographics
NPI:1376806596
Name:SULLIVAN, MATTHEW SEAN (LMT)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:SEAN
Last Name:SULLIVAN
Suffix:
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 1:120 BAYSHORE RD
Mailing Address - Street 2:
Mailing Address - City:NOKOMIS
Mailing Address - State:FL
Mailing Address - Zip Code:34275-1904
Mailing Address - Country:US
Mailing Address - Phone:941-350-1669
Mailing Address - Fax:
Practice Address - Street 1:4370 S TAMIAMI TRL
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34231-3412
Practice Address - Country:US
Practice Address - Phone:941-350-1669
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-21
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA68340225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist