Provider Demographics
NPI:1518027333
Name:SULLIVAN, MARYELLEN (PT, MS, DPT)
Entity Type:Individual
Prefix:DR
First Name:MARYELLEN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT, MS, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2781 COTTONWOOD CT
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33761-3809
Mailing Address - Country:US
Mailing Address - Phone:727-726-8627
Mailing Address - Fax:
Practice Address - Street 1:32672 US 19 N
Practice Address - Street 2:
Practice Address - City:PALM HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34684
Practice Address - Country:US
Practice Address - Phone:727-772-2216
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT00007331225100000X
MAPT4152225100000X
WIPT2502-024225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist