Basic Information
| Provider Information | |||||||||
| NPI: | 1396404471 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MEGAN | ||||||||
| MiddleName: | VIRGINIA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1031 S SCENIC HWY | ||||||||
| Address2: | |||||||||
| City: | LAKE WALES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338534823 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8636329550 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 6120 US HIGHWAY 27 N | ||||||||
| Address2: | |||||||||
| City: | SEBRING | ||||||||
| State: | FL | ||||||||
| PostalCode: | 338701221 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8634711223 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/15/2021 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 31674 | FL | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.