Healthcare Provider Details

I. General information

NPI: 1104485689
Provider Name (Legal Business Name): LAUREN K SULLIVAN DPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2019
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3726 S KINGSHIGHWAY BLVD
SAINT LOUIS MO
63109-1800
US

IV. Provider business mailing address

600 OAKMONT LN STE 600C
WESTMONT IL
60559-5548
US

V. Phone/Fax

Practice location:
  • Phone: 314-351-5150
  • Fax: 314-351-6885
Mailing address:
  • Phone: 630-575-6250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number070024396
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2020034322
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: