Provider Demographics
NPI:1669794699
Name:SULLIVAN, CAROLYN SHANNON (LIC AC)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:SHANNON
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LIC AC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15 EDGECLIFF RD
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02472-3544
Mailing Address - Country:US
Mailing Address - Phone:617-458-0530
Mailing Address - Fax:
Practice Address - Street 1:387 QUARRY ST
Practice Address - Street 2:NATIONAL PHYSICAL THERAPY
Practice Address - City:FALL RIVER
Practice Address - State:MA
Practice Address - Zip Code:02723-1025
Practice Address - Country:US
Practice Address - Phone:508-324-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-17
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist