Basic Information
| Provider Information | |||||||||
| NPI: | 1518478189 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | DAVID | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15945 | ||||||||
| Address2: | |||||||||
| City: | BELFAST | ||||||||
| State: | ME | ||||||||
| PostalCode: | 049154054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107294508 | ||||||||
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| Practice Location | |||||||||
| Address1: | 70 CENTRAL AVE W | ||||||||
| Address2: | |||||||||
| City: | EDGEWATER | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210372622 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4437755640 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/23/2017 | ||||||||
| LastUpdateDate: | 08/20/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/20/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | J1-0014238 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.