Provider Demographics
NPI:1851493357
Name:SULLIVAN, WILLIAM JOSEPH (MPT)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:JOSEPH
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 1:5125 SKYLINE RD S
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-9427
Mailing Address - Country:US
Mailing Address - Phone:503-315-4662
Mailing Address - Fax:
Practice Address - Street 1:5125 SKYLINE RD S
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97306-9427
Practice Address - Country:US
Practice Address - Phone:503-315-4662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-04
Last Update Date:2007-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2614225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist