Provider Demographics
NPI:1750734992
Name:SULLIVAN, KEVIN (MS, LAT, ATC)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:936 WYNN RD
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-5802
Mailing Address - Country:US
Mailing Address - Phone:404-314-4754
Mailing Address - Fax:
Practice Address - Street 1:936 WYNN RD
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30252-5802
Practice Address - Country:US
Practice Address - Phone:404-314-4754
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-22
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0026772255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer