Provider Demographics
NPI:1942438064
Name:SULLIVAN, MARSHALL
Entity Type:Individual
Prefix:
First Name:MARSHALL
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:346 SPRUCEWOOD LN
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-6414
Mailing Address - Country:US
Mailing Address - Phone:210-737-4291
Mailing Address - Fax:
Practice Address - Street 1:346 SPRUCEWOOD LN
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-6414
Practice Address - Country:US
Practice Address - Phone:210-737-4291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-26
Last Update Date:2009-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2070353225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant