Provider Demographics
NPI:1881767614
Name:SULLIVAN, ELIZABETH W (PT)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:W
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:141 ATRIUM WAY
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6301
Mailing Address - Country:US
Mailing Address - Phone:803-788-8484
Mailing Address - Fax:803-788-8499
Practice Address - Street 1:229 SALUDA SPRINGS RD
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:SC
Practice Address - Zip Code:29072
Practice Address - Country:US
Practice Address - Phone:803-359-0505
Practice Address - Fax:803-359-2206
Is Sole Proprietor?:No
Enumeration Date:2006-11-17
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8251225100000X
MD220582251S0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCTH3382Medicaid
MDH370P754Medicare PIN