Provider Demographics
NPI:1649936212
Name:FROSS, SULLIVAN (PTA)
Entity type:Individual
Prefix:
First Name:SULLIVAN
Middle Name:
Last Name:FROSS
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13221 ILLINOIS ST
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-2609
Mailing Address - Country:US
Mailing Address - Phone:714-791-4866
Mailing Address - Fax:
Practice Address - Street 1:4950 BARRANCA PKWY STE 302
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4631
Practice Address - Country:US
Practice Address - Phone:949-346-1486
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-09
Last Update Date:2021-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51500225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant