Basic Information
| Provider Information | |||||||||
| NPI: | 1710931209 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | M | ||||||||
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| Credential: | MPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 32 STONELAND RD | ||||||||
| Address2: | |||||||||
| City: | SHREWSBURY | ||||||||
| State: | MA | ||||||||
| PostalCode: | 015454454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6305507176 | ||||||||
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| Practice Location | |||||||||
| Address1: | 15 BELMONT ST | ||||||||
| Address2: | |||||||||
| City: | WORCESTER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 016052650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5083348700 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 10/07/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 22024 | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.