Provider Demographics
NPI:1336575398
Name:SULLIVAN, DARYLE (LMT)
Entity Type:Individual
Prefix:MR
First Name:DARYLE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9501 STATE AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:MARYSVILLE
Mailing Address - State:WA
Mailing Address - Zip Code:98270-2235
Mailing Address - Country:US
Mailing Address - Phone:360-651-8264
Mailing Address - Fax:360-658-9021
Practice Address - Street 1:9501 STATE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MARYSVILLE
Practice Address - State:WA
Practice Address - Zip Code:98270-2235
Practice Address - Country:US
Practice Address - Phone:360-651-8264
Practice Address - Fax:360-658-9021
Is Sole Proprietor?:Yes
Enumeration Date:2013-09-23
Last Update Date:2013-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00008878225700000X
TXMT110567225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist