Provider Demographics
NPI:1578097416
Name:SULLIVAN, HALEY (ATC, LAT)
Entity Type:Individual
Prefix:
First Name:HALEY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:HUNTINGDON
Mailing Address - State:TN
Mailing Address - Zip Code:38344-3908
Mailing Address - Country:US
Mailing Address - Phone:731-415-3329
Mailing Address - Fax:
Practice Address - Street 1:15 MOUNT PELIA RD
Practice Address - Street 2:1022 ELAM CENTER
Practice Address - City:MARTIN
Practice Address - State:TN
Practice Address - Zip Code:38237-3313
Practice Address - Country:US
Practice Address - Phone:731-881-7679
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-18
Last Update Date:2017-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21692255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer