MEDICARE: MR. SEAN RAYMOND SULLIVAN DPT, ATC

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	13432	CT
2	225100000X	Physical Therapist	21328	MA

General Provider Information

NPI Number	:	1669871604
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SEAN RAYMOND SULLIVAN DPT, ATC

Provider Business Mailing Address
First Line	:	576 BROADHOLLOW RD
Second Line	:
City	:	MELVILLE
State	:	NY
Zip	:	11747-5002
Country	:	US
Telephone Number	:	631-359-5800
Fax Number	:

Provider Business Practice Location Address
First Line	:	1290 SUMMER ST STE 2000
Second Line	:
City	:	STAMFORD
State	:	CT
Zip	:	06905-5339
Country	:	US
Telephone Number	:	203-989-2691
Fax Number	:

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

Provider Enumeration Date	:	08/15/2014
Last Update Date	:	04/10/2023

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