Basic Information
Provider Information | |||||||||
NPI: | 1396808523 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | SULLIVAN | ||||||||
FirstName: | CATHERINE | ||||||||
MiddleName: | RAY | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MPT | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 403 WOODRIDGE DR | ||||||||
Address2: |   | ||||||||
City: | SENECA | ||||||||
State: | SC | ||||||||
PostalCode: | 296722441 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8649851944 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 100 HEALTHY WAY STE 1110 | ||||||||
Address2: |   | ||||||||
City: | ANDERSON | ||||||||
State: | SC | ||||||||
PostalCode: | 296212067 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8642613099 | ||||||||
FaxNumber: | 8642616617 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/19/2006 | ||||||||
LastUpdateDate: | 07/08/2007 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X | 3854 | SC | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.