Provider Demographics
NPI:1780463042
Name:SULLIVAN, CHERYL ANNE (LMT)
Entity type:Individual
Prefix:
First Name:CHERYL
Middle Name:ANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3945 SOMERLED TRL
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30349-2035
Mailing Address - Country:US
Mailing Address - Phone:678-592-6059
Mailing Address - Fax:
Practice Address - Street 1:910 DANNON VW SW STE 2202
Practice Address - Street 2:
Practice Address - City:SOUTH FULTON
Practice Address - State:GA
Practice Address - Zip Code:30331-2156
Practice Address - Country:US
Practice Address - Phone:678-592-6059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT012950225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist