Provider Demographics
NPI:1811720659
Name:SULLIVAN, REILLY DAVID (PTA)
Entity type:Individual
Prefix:
First Name:REILLY
Middle Name:DAVID
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1420 LAKE SHADOW CIR APT 9307
Mailing Address - Street 2:
Mailing Address - City:MAITLAND
Mailing Address - State:FL
Mailing Address - Zip Code:32751-7582
Mailing Address - Country:US
Mailing Address - Phone:412-956-7217
Mailing Address - Fax:
Practice Address - Street 1:60 COLUMBIA ST STE 501
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32806-1115
Practice Address - Country:US
Practice Address - Phone:412-956-7217
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA31394225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant