Provider Demographics
NPI:1467632919
Name:SULLIVAN, JUSTIN (DPT)
Entity Type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:360 STATE ROUTE 17M STE 4
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NY
Mailing Address - Zip Code:10950-3444
Mailing Address - Country:US
Mailing Address - Phone:845-810-0078
Mailing Address - Fax:845-262-2466
Practice Address - Street 1:360 STATE ROUTE 17M STE 4
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NY
Practice Address - Zip Code:10950-3444
Practice Address - Country:US
Practice Address - Phone:845-810-0078
Practice Address - Fax:845-262-2466
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-13
Last Update Date:2011-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01265000225100000X
NY62 033294225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist