Provider Demographics
NPI:1770669947
Name:SULLIVAN, MARTHA L (PT)
Entity Type:Individual
Prefix:MRS
First Name:MARTHA
Middle Name:L
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 1:2306 N 7TH STREET
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47804
Mailing Address - Country:US
Mailing Address - Phone:812-234-3267
Mailing Address - Fax:
Practice Address - Street 1:4146 S 7TH STREET
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802
Practice Address - Country:US
Practice Address - Phone:812-242-2332
Practice Address - Fax:812-242-2772
Is Sole Proprietor?:No
Enumeration Date:2006-10-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN05001527A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000213923OtherBLUE CROSS BLUE SHIELD
P45805Medicare UPIN
IN185940BMedicare ID - Type Unspecified