Provider Demographics
NPI:1972114882
Name:SULLIVAN, MICHAEL ASHBY
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ASHBY
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 1:5 BALDWIN DR
Mailing Address - Street 2:
Mailing Address - City:FREDERICKSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:22406-6264
Mailing Address - Country:US
Mailing Address - Phone:540-751-8750
Mailing Address - Fax:
Practice Address - Street 1:2152 JEFFERSON DAVIS HWY
Practice Address - Street 2:
Practice Address - City:STAFFORD
Practice Address - State:VA
Practice Address - Zip Code:22554-7273
Practice Address - Country:US
Practice Address - Phone:540-751-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-13
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0019012217225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist