Provider Demographics
NPI:1245695402
Name:SULLIVAN, PAUL (PT, DPT)
Entity type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:833 CHESTNUT ST
Mailing Address - Street 2:STE 1402
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-4404
Mailing Address - Country:US
Mailing Address - Phone:800-321-9999
Mailing Address - Fax:267-339-3761
Practice Address - Street 1:34 MANCHESTER AVE
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-1366
Practice Address - Country:US
Practice Address - Phone:609-693-9345
Practice Address - Fax:609-693-9347
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-15
Last Update Date:2016-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01649500225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist