Provider Demographics
NPI:1366963456
Name:SULLIVAN, THOMAS PATRICK (PTA)
Entity type:Individual
Prefix:MR
First Name:THOMAS
Middle Name:PATRICK
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14519 KINGSCROSS CIR NW
Mailing Address - Street 2:
Mailing Address - City:SILVERDALE
Mailing Address - State:WA
Mailing Address - Zip Code:98383-7996
Mailing Address - Country:US
Mailing Address - Phone:360-261-5425
Mailing Address - Fax:
Practice Address - Street 1:560 LEBO BLVD
Practice Address - Street 2:
Practice Address - City:BREMERTON
Practice Address - State:WA
Practice Address - Zip Code:98310-2617
Practice Address - Country:US
Practice Address - Phone:360-479-1515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-29
Last Update Date:2017-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAP160732078225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy AssistantGroup - Single Specialty