Provider Demographics
NPI:1629497672
Name:SULLIVAN, WENDY
Entity Type:Individual
Prefix:
First Name:WENDY
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 1:505 SPOKANE AVE
Mailing Address - Street 2:P.O. BOX 13
Mailing Address - City:WHITEFISH
Mailing Address - State:MT
Mailing Address - Zip Code:59937-2780
Mailing Address - Country:US
Mailing Address - Phone:406-250-7848
Mailing Address - Fax:
Practice Address - Street 1:505 SPOKANE AVE
Practice Address - Street 2:505 SPOKANE AVE.
Practice Address - City:WHITEFISH
Practice Address - State:MT
Practice Address - Zip Code:59937-2780
Practice Address - Country:US
Practice Address - Phone:406-250-7848
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-414225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist