Provider Demographics
NPI:1831107051
Name:SULLIVAN, MICHAEL (MPT)
Entity Type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12980 BANDERA RD
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-4098
Mailing Address - Country:US
Mailing Address - Phone:210-372-9600
Mailing Address - Fax:210-362-9923
Practice Address - Street 1:12980 BANDERA RD
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4098
Practice Address - Country:US
Practice Address - Phone:210-372-9600
Practice Address - Fax:210-362-9923
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1161449225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8T4496OtherBLUE CROSS/SHIELD
TX8T4496OtherBLUE CROSS/SHIELD