MEDICARE: CHERYL ANNE SULLIVAN LMT

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	225700000X	Massage Therapist	MT012950	GA

General Provider Information

NPI Number	:	1780463042
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL ANNE SULLIVAN LMT

Provider Business Mailing Address
First Line	:	3945 SOMERLED TRL
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30349-2035
Country	:	US
Telephone Number	:	678-592-6059
Fax Number	:

Provider Business Practice Location Address
First Line	:	910 DANNON VW SW STE 2202
Second Line	:
City	:	SOUTH FULTON
State	:	GA
Zip	:	30331-2156
Country	:	US
Telephone Number	:	678-592-6059
Fax Number	:

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

Provider Enumeration Date	:	09/26/2023
Last Update Date	:	09/26/2023

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