Provider Demographics
NPI:1134170442
Name:SULLIVAN, MARIANNE (PT)
Entity type:Individual
Prefix:
First Name:MARIANNE
Middle Name:
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 1:28371 CAMINO DIMORA
Mailing Address - Street 2:
Mailing Address - City:SAN JUAN CAPISTRANO
Mailing Address - State:CA
Mailing Address - Zip Code:92675-6300
Mailing Address - Country:US
Mailing Address - Phone:310-962-4203
Mailing Address - Fax:
Practice Address - Street 1:31271 NIGUEL RD STE J
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-4135
Practice Address - Country:US
Practice Address - Phone:949-443-5442
Practice Address - Fax:949-443-5436
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2023-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 18597225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT18597AMedicare ID - Type Unspecified