MEDICARE: MARLYSA SULLIVAN PT

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	PT007465	GA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PT007465	OTHER	GA	STATE LISC NUMBER

General Provider Information

NPI Number	:	1578632816
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARLYSA SULLIVAN PT

Provider Business Mailing Address
First Line	:	3901 LOCH RAVEN BLVD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-2109
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3901 LOCH RAVEN BLVD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21218-2109
Country	:	US
Telephone Number	:	404-791-5230
Fax Number	:

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

Provider Enumeration Date	:	11/08/2006
Last Update Date	:	02/10/2026

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