Provider Demographics
NPI:1023152774
Name:SULLIVAN, RICHARD (MSPT)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MSPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:790 REMINGTON BLVD
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-4909
Mailing Address - Country:US
Mailing Address - Phone:630-296-2223
Mailing Address - Fax:630-759-9510
Practice Address - Street 1:22830 & 22832 SUSSEX HIGHWAY
Practice Address - Street 2:SUITE 13 & 14
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-5862
Practice Address - Country:US
Practice Address - Phone:302-536-5562
Practice Address - Fax:302-628-5313
Is Sole Proprietor?:No
Enumeration Date:2007-02-16
Last Update Date:2016-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEJ10001608225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist