Provider Demographics
NPI:1760494090
Name:SULLIVAN, COLLEEN CRONIN (PT)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:CRONIN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:COLLEN
Other - Middle Name:E
Other - Last Name:CRONIN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:73 NEWTON RD
Mailing Address - Street 2:STE 101
Mailing Address - City:PLAISTOW
Mailing Address - State:NH
Mailing Address - Zip Code:03865-2424
Mailing Address - Country:US
Mailing Address - Phone:978-388-7272
Mailing Address - Fax:978-388-7373
Practice Address - Street 1:1350 SULLIVAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTH WINDSOR
Practice Address - State:CT
Practice Address - Zip Code:06074-2713
Practice Address - Country:US
Practice Address - Phone:860-697-6472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2018-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT005876225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004185585Medicaid
CT080005876CT26OtherANTHEM # SW PT PLUS
CT650001086Medicare PIN