Provider Demographics
NPI:1588892863
Name:SULLIVAN, LORI (MSPT)
Entity type:Individual
Prefix:MS
First Name:LORI
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSPT
Other - Prefix:
Other - First Name:LORI
Other - Middle Name:JO
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:6804 S KINGS RANCH RD
Mailing Address - Street 2:STE 103
Mailing Address - City:GOLD CANYON
Mailing Address - State:AZ
Mailing Address - Zip Code:85118-2960
Mailing Address - Country:US
Mailing Address - Phone:480-983-8600
Mailing Address - Fax:
Practice Address - Street 1:6804 S KINGS RANCH RD
Practice Address - Street 2:STE 103
Practice Address - City:GOLD CANYON
Practice Address - State:AZ
Practice Address - Zip Code:85118-2960
Practice Address - Country:US
Practice Address - Phone:480-983-8600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501010318225100000X
AZLPT-307502251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist