Provider Demographics
NPI:1396404471
Name:SULLIVAN, MEGAN VIRGINIA (PTA)
Entity Type:Individual
Prefix:MRS
First Name:MEGAN
Middle Name:VIRGINIA
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 1:1031 S SCENIC HWY
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4823
Mailing Address - Country:US
Mailing Address - Phone:863-632-9550
Mailing Address - Fax:
Practice Address - Street 1:6120 US HIGHWAY 27 N
Practice Address - Street 2:
Practice Address - City:SEBRING
Practice Address - State:FL
Practice Address - Zip Code:33870-1221
Practice Address - Country:US
Practice Address - Phone:863-471-1223
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-15
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL31674225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant