Provider Demographics
NPI:1669871604
Name:SULLIVAN, SEAN RAYMOND (DPT, ATC)
Entity type:Individual
Prefix:MR
First Name:SEAN
Middle Name:RAYMOND
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:DPT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:576 BROADHOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-5002
Mailing Address - Country:US
Mailing Address - Phone:631-359-5800
Mailing Address - Fax:
Practice Address - Street 1:1290 SUMMER ST STE 2000
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06905-5339
Practice Address - Country:US
Practice Address - Phone:203-989-2691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-15
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT13432225100000X
MA21328225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist