Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 225100000X | Physical Therapist | 003846 | CT |
N | 2251S0007X | Physical Therapist - Sports | 003846 | CT |
N | 2251X0800X | Physical Therapist - Orthopedic | 003846 | CT |
NPI | 1306874227 |
---|---|
Provider Name | Mr. Mark Allen Sullivan |
First Address | Agawam, MA 01001-3238 |
Second Address | Suffield, CT 06078-2084 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 29/06/2006 |
Last Update Date | 08/07/2007 |