Provider Demographics
NPI:1447297429
Name:SULLIVAN, COLLEEN M (MPT)
Entity type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MPT
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:M
Other - Last Name:SULLIVAN-PRICE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MPT
Mailing Address - Street 1:805 SW INDUSTRIAL WAY
Mailing Address - Street 2:STE 3
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-1093
Mailing Address - Country:US
Mailing Address - Phone:541-585-2541
Mailing Address - Fax:541-585-2536
Practice Address - Street 1:1160 SW SIMPSON AVE
Practice Address - Street 2:STE 200
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3542
Practice Address - Country:US
Practice Address - Phone:541-322-9045
Practice Address - Fax:541-322-9044
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2013-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPT00006727225100000X
OR60371225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAP44251Medicare UPIN