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General NPI Number Information
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NPI Number | 1760300495
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Entity Type | Individual
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Provider Name | MARY ABIGAIL SULLIVAN
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Gender | Female
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Dates
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Enumeration Date | 07/09/2026
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Last Update Date | 07/09/2026
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Provider Practice Location Address
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Address Line | 613 WESTLAKE ST STE 130
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City | ENCINITAS
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State | CA
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Zip | 92024-3866
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Country | US
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Telephone | 858-755-5200
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Fax |
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Provider Business Mailing Address
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Address Line | 2251 ED LITTLE RD
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City | CRESTON
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State | NC
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Zip | 28615-8604
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Country | US
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Telephone | 336-977-5740
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225100000X
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Taxonomy Name | Physical Therapist
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License Number | 310431
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License Number State | CA
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