Healthcare Provider Details

I. General information

NPI: 1629523568
Provider Name (Legal Business Name): KERRY SULLIVAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2016
Last Update Date: 08/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 S CALIFORNIA AVE
CHICAGO IL
60608-1858
US

IV. Provider business mailing address

2740 W LOGAN BLVD APT 6
CHICAGO IL
60647-1856
US

V. Phone/Fax

Practice location:
  • Phone: 773-522-2010
  • Fax:
Mailing address:
  • Phone: 914-474-2851
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number070021507
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: