Provider Demographics
NPI:1861650970
Name:SULLIVAN, STEPHANIE M (DPT)
Entity type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:911 E 86TH ST STE 103
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46240-1840
Mailing Address - Country:US
Mailing Address - Phone:866-360-9355
Mailing Address - Fax:
Practice Address - Street 1:800 GRAYSON LN
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45430-1783
Practice Address - Country:US
Practice Address - Phone:866-360-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-26
Last Update Date:2024-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS11-03805225100000X
OHPT021352.MIL225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist