Provider Demographics
NPI:1710060918
Name:SULLIVAN, SHELLEY (PT)
Entity Type:Individual
Prefix:MRS
First Name:SHELLEY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1309 HARRISON AVE
Mailing Address - Street 2:
Mailing Address - City:BUTTE
Mailing Address - State:MT
Mailing Address - Zip Code:59701-4801
Mailing Address - Country:US
Mailing Address - Phone:406-782-5887
Mailing Address - Fax:406-782-8772
Practice Address - Street 1:1309 HARRISON AVE
Practice Address - Street 2:
Practice Address - City:BUTTE
Practice Address - State:MT
Practice Address - Zip Code:59701-4801
Practice Address - Country:US
Practice Address - Phone:406-782-5887
Practice Address - Fax:406-782-8772
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-23
Last Update Date:2008-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT786PT2251X0800X, 225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist