Provider Demographics
NPI:1760496392
Name:SULLIVAN, TIMOTHY JOSEPH (PT)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:604 N SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5921
Mailing Address - Country:US
Mailing Address - Phone:310-374-0477
Mailing Address - Fax:310-374-1605
Practice Address - Street 1:604 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5921
Practice Address - Country:US
Practice Address - Phone:310-374-0477
Practice Address - Fax:310-374-1605
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2013-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT23153225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPT23153OtherPHYSICAL THERAPY LICENSE