Provider Demographics
| NPI: | 1831882976 |
|---|---|
| Name: | SULLIVAN, MADELINE KLAIRE (DPT) |
| Entity type: | Individual |
| Prefix: | |
| First Name: | MADELINE |
| Middle Name: | KLAIRE |
| Last Name: | SULLIVAN |
| Suffix: | |
| Gender: | F |
| Credentials: | DPT |
| Other - Prefix: | |
| Other - First Name: | MADELINE |
| Other - Middle Name: | KLAIRE |
| Other - Last Name: | MAYNARD |
| Other - Suffix: | |
| Other - Last Name Type: | Former Name |
| Other - Credentials: | |
| Mailing Address - Street 1: | 1408 VICTORIA LN |
| Mailing Address - Street 2: | |
| Mailing Address - City: | BRANDON |
| Mailing Address - State: | MS |
| Mailing Address - Zip Code: | 39042-6089 |
| Mailing Address - Country: | US |
| Mailing Address - Phone: | |
| Mailing Address - Fax: | |
| Practice Address - Street 1: | 300 3RD AVE SE |
| Practice Address - Street 2: | |
| Practice Address - City: | MAGEE |
| Practice Address - State: | MS |
| Practice Address - Zip Code: | 39111-3665 |
| Practice Address - Country: | US |
| Practice Address - Phone: | 601-849-5070 |
| Practice Address - Fax: | |
| Is Sole Proprietor?: | No |
| Enumeration Date: | 2023-06-02 |
| Last Update Date: | 2023-06-02 |
| Deactivation Date: | |
| Deactivation Code: | |
| Reactivation Date: |
Provider Licenses
| State | License ID | Taxonomies |
|---|---|---|
| 2251P0200X, 2251S0007X, 2251H1200X, 2251H1300X, 2251N0400X, 2251E1200X, 2251E1300X, 2251C2600X, 2251X0800X, 225100000X | ||
| MS | PT7542 | 2251G0304X |
Provider Taxonomies
| Primary? | Code | Type | Classification | Specialization |
|---|---|---|---|---|
| Yes | 225100000X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | |
| No | 2251P0200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Pediatrics |
| No | 2251S0007X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Sports |
| No | 2251H1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Hand |
| No | 2251H1300X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Human Factors |
| No | 2251N0400X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Neurology |
| No | 2251E1200X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Ergonomics |
| No | 2251E1300X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Electrophysiology, Clinical |
| No | 2251C2600X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Cardiopulmonary |
| No | 2251G0304X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Geriatrics |
| No | 2251X0800X | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
