Provider Demographics
NPI:1013128412
Name:SULLIVAN, LORI M (PT)
Entity Type:Individual
Prefix:
First Name:LORI
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 WIDGEON DR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4759
Mailing Address - Country:US
Mailing Address - Phone:252-240-1832
Mailing Address - Fax:
Practice Address - Street 1:534 NORTH 35TH STREET SUITE D
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557
Practice Address - Country:US
Practice Address - Phone:252-726-1802
Practice Address - Fax:252-726-1805
Is Sole Proprietor?:No
Enumeration Date:2007-05-25
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2269174400000X
225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC205119OtherP-TAN