Healthcare Provider Details

I. General information

NPI: 1528675543
Provider Name (Legal Business Name): LAUREN SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

291 CARL BROGGI HWY
LEBANON ME
04027-3405
US

IV. Provider business mailing address

291 CARL BROGGI HWY
LEBANON ME
04027-3405
US

V. Phone/Fax

Practice location:
  • Phone: 207-457-6037
  • Fax:
Mailing address:
  • Phone: 603-988-5785
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: