Basic Information
| Provider Information | |||||||||
| NPI: | 1760494090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | COLLEEN | ||||||||
| MiddleName: | CRONIN | ||||||||
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| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | CRONIN | ||||||||
| OtherFirstName: | COLLEN | ||||||||
| OtherMiddleName: | E | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 73 NEWTON RD | ||||||||
| Address2: | STE 101 | ||||||||
| City: | PLAISTOW | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038652424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9783887272 | ||||||||
| FaxNumber: | 9783887373 | ||||||||
| Practice Location | |||||||||
| Address1: | 1350 SULLIVAN AVE | ||||||||
| Address2: | |||||||||
| City: | SOUTH WINDSOR | ||||||||
| State: | CT | ||||||||
| PostalCode: | 060742713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8606976472 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/13/2006 | ||||||||
| LastUpdateDate: | 01/19/2018 | ||||||||
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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 | 005876 | CT | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 004185585 | 05 | CT | MEDICAID | 080005876CT26 | 01 | CT | ANTHEM # SW PT PLUS | OTHER |