Provider Demographics
NPI:1003345554
Name:SULLIVAN, BRIDGET (ATC)
Entity type:Individual
Prefix:
First Name:BRIDGET
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:126 BROOKSTOWN AVE APT 150
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27101-5377
Mailing Address - Country:US
Mailing Address - Phone:615-491-3014
Mailing Address - Fax:
Practice Address - Street 1:4030 WELLMAN WAY
Practice Address - Street 2:MILLER CENTER
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27109
Practice Address - Country:US
Practice Address - Phone:336-758-4188
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-08
Last Update Date:2024-10-11
Deactivation Date:2017-12-05
Deactivation Code:
Reactivation Date:2024-09-26
Provider Licenses
StateLicense IDTaxonomies
NCLAT-46972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer