Provider Demographics
NPI:1629523568
Name:SULLIVAN, KERRY (DPT)
Entity Type:Individual
Prefix:DR
First Name:KERRY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 W LOGAN BLVD
Mailing Address - Street 2:APT 6
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60647-1856
Mailing Address - Country:US
Mailing Address - Phone:914-474-2851
Mailing Address - Fax:
Practice Address - Street 1:1401 S CALIFORNIA AVE
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60608-1858
Practice Address - Country:US
Practice Address - Phone:773-522-2010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-21
Last Update Date:2016-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070021507283X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes283X00000XHospitalsRehabilitation Hospital