Provider Demographics
NPI:1790422426
Name:SULLIVAN, BIANCA (LMBT)
Entity Type:Individual
Prefix:MS
First Name:BIANCA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4913 PROFESSIONAL CT STE 208
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-1926
Mailing Address - Country:US
Mailing Address - Phone:910-548-4896
Mailing Address - Fax:
Practice Address - Street 1:4913 PROFESSIONAL CT STE 208
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-1926
Practice Address - Country:US
Practice Address - Phone:910-548-4896
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-15
Last Update Date:2022-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18017225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist