Provider Demographics
NPI:1265551634
Name:SULLIVAN, DEIDRA L (DPT)
Entity type:Individual
Prefix:MISS
First Name:DEIDRA
Middle Name:L
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 LONGBRANCH AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKPORT
Mailing Address - State:MA
Mailing Address - Zip Code:01966-1115
Mailing Address - Country:US
Mailing Address - Phone:978-546-9290
Mailing Address - Fax:
Practice Address - Street 1:57 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:MA
Practice Address - Zip Code:01970-2141
Practice Address - Country:US
Practice Address - Phone:978-354-2746
Practice Address - Fax:978-740-4960
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA16451225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist