Healthcare Provider Details

I. General information

NPI: 1477070522
Provider Name (Legal Business Name): SCOTT SULLIVAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

439 CHANNEL RD STE 102
LAKE WYLIE SC
29710-6101
US

IV. Provider business mailing address

PO BOX 412066
BOSTON MA
02241-2066
US

V. Phone/Fax

Practice location:
  • Phone: 803-746-7800
  • Fax:
Mailing address:
  • Phone: 914-294-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number20579
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code2251X0800X
TaxonomyOrthopedic Physical Therapist
License NumberPTL.0015126
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number12553
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: