Provider Demographics
NPI:1427137249
Name:SULLIVAN, SHAWN CHRISTOPHER (PT)
Entity type:Individual
Prefix:
First Name:SHAWN
Middle Name:CHRISTOPHER
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:512 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4788
Mailing Address - Country:US
Mailing Address - Phone:860-343-5997
Mailing Address - Fax:860-343-6042
Practice Address - Street 1:512 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4788
Practice Address - Country:US
Practice Address - Phone:860-343-5997
Practice Address - Fax:860-343-6042
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2009-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPT003689225100000X
OHPT10441225100000X
CT006342225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT7691516OtherAETNA
CT080006342CT01OtherANTHEM BCBS
CT3V1439OtherPHS HEALTHNET
CT761899OtherCONNECTICARE
CT7691516OtherAETNA