Provider Demographics
NPI:1083439533
Name:SULLIVAN, WILLIAM (LMT)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:553 BRANNON MEADOW WAY
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-8082
Mailing Address - Country:US
Mailing Address - Phone:859-304-2635
Mailing Address - Fax:
Practice Address - Street 1:2459 NICHOLASVILLE RD # 50
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3181
Practice Address - Country:US
Practice Address - Phone:859-300-4378
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY244400225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist