Healthcare Provider Details

I. General information

NPI: 1760300495
Provider Name (Legal Business Name): MARY ABIGAIL SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/09/2026
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

613 WESTLAKE ST STE 130
ENCINITAS CA
92024-3866
US

IV. Provider business mailing address

2251 ED LITTLE RD
CRESTON NC
28615-8604
US

V. Phone/Fax

Practice location:
  • Phone: 858-755-5200
  • Fax:
Mailing address:
  • Phone: 336-977-5740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number310431
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: