Provider Demographics
NPI:1306874227
Name:SULLIVAN, MARK ALLEN (MBA, PT, ATC)
Entity type:Individual
Prefix:MR
First Name:MARK
Middle Name:ALLEN
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MBA, PT, ATC
Other - Prefix:
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Mailing Address - Street 1:40 HEARTHSTONE DR
Mailing Address - Street 2:
Mailing Address - City:AGAWAM
Mailing Address - State:MA
Mailing Address - Zip Code:01001-3238
Mailing Address - Country:US
Mailing Address - Phone:413-789-2168
Mailing Address - Fax:860-254-5982
Practice Address - Street 1:133 MOUNTAIN RD
Practice Address - Street 2:SUITE 2B.
Practice Address - City:SUFFIELD
Practice Address - State:CT
Practice Address - Zip Code:06078-2084
Practice Address - Country:US
Practice Address - Phone:860-254-5982
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT003846225100000X, 2251S0007X, 2251X0800X
MA1162255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Not Answered2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
Not Answered2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Not Answered2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer