Provider Demographics
NPI:1477058436
Name:SULLIVAN, RAIKESHA
Entity Type:Individual
Prefix:
First Name:RAIKESHA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9930 WHIP POOR WILL DR
Mailing Address - Street 2:
Mailing Address - City:SEMMES
Mailing Address - State:AL
Mailing Address - Zip Code:36575-7026
Mailing Address - Country:US
Mailing Address - Phone:251-623-9320
Mailing Address - Fax:
Practice Address - Street 1:18700 US HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567-3271
Practice Address - Country:US
Practice Address - Phone:251-947-1911
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTA6790225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant