Provider Demographics
NPI:1124488796
Name:SULLIVAN, AMY E (DPT)
Entity type:Individual
Prefix:
First Name:AMY
Middle Name:E
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:AMY
Other - Middle Name:
Other - Last Name:GOSS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:4 RICHMOND SQ STE 200
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02906-5117
Mailing Address - Country:US
Mailing Address - Phone:401-433-4172
Mailing Address - Fax:401-433-0612
Practice Address - Street 1:41 SANDERSON ROAD
Practice Address - Street 2:SUITE 101
Practice Address - City:SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02917-2611
Practice Address - Country:US
Practice Address - Phone:401-349-4540
Practice Address - Fax:401-349-4510
Is Sole Proprietor?:No
Enumeration Date:2016-02-25
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPT02887225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist