Provider Demographics
NPI:1174724686
Name:SULLIVAN, BRENDAN MICHAEL (PT, FACHE)
Entity type:Individual
Prefix:
First Name:BRENDAN
Middle Name:MICHAEL
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT, FACHE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14912 HIGH BLUFF CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28278-4402
Mailing Address - Country:US
Mailing Address - Phone:610-906-9103
Mailing Address - Fax:
Practice Address - Street 1:134 PROFESSIONAL PARK DR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-1178
Practice Address - Country:US
Practice Address - Phone:704-863-4878
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-31
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT018313225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist