MEDICARE: JOHNANNA SULLIVAN PT, DPT, OCS, SCS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	8331	CO
2	225100000X	Physical Therapist	PTP-PT-LIC-5810	MT

General Provider Information

NPI Number	:	1447335724
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOHNANNA SULLIVAN PT, DPT, OCS, SCS

Provider Business Mailing Address
First Line	:	1130 W WOODMEN RD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80919-2726
Country	:	US
Telephone Number	:	719-574-5562
Fax Number	:	719-471-0445

Provider Business Practice Location Address
First Line	:	3150 N MONTANA AVE STE D
Second Line	:
City	:	HELENA
State	:	MT
Zip	:	59602-7804
Country	:	US
Telephone Number	:	719-659-6088
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/21/2022

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