Provider Demographics
NPI:1710353081
Name:SULLIVAN, JEREMIAH (DPT)
Entity Type:Individual
Prefix:
First Name:JEREMIAH
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1857 GULF TO BAY BLVD
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33765-3415
Mailing Address - Country:US
Mailing Address - Phone:727-408-5222
Mailing Address - Fax:727-408-5252
Practice Address - Street 1:1857 GULF TO BAY BLVD
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33765-3415
Practice Address - Country:US
Practice Address - Phone:727-408-5222
Practice Address - Fax:727-408-5252
Is Sole Proprietor?:No
Enumeration Date:2015-08-20
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPT30563225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist