Provider Demographics
NPI:1497131445
Name:SULLIVAN, ANDREW (PT, DPT)
Entity Type:Individual
Prefix:MR
First Name:ANDREW
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1251 14TH ST
Mailing Address - Street 2:APT 103
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-1013
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6041 CADILLAC AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90034-1702
Practice Address - Country:US
Practice Address - Phone:323-857-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2017-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT14.010583225100000X
CA291552225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist