Provider Demographics
NPI:1447335724
Name:SULLIVAN, JOHNANNA (PT, DPT, OCS, SCS)
Entity type:Individual
Prefix:
First Name:JOHNANNA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT, DPT, OCS, SCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1130 W WOODMEN RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80919-2726
Mailing Address - Country:US
Mailing Address - Phone:719-574-5562
Mailing Address - Fax:719-471-0445
Practice Address - Street 1:3150 N MONTANA AVE STE D
Practice Address - Street 2:
Practice Address - City:HELENA
Practice Address - State:MT
Practice Address - Zip Code:59602-7804
Practice Address - Country:US
Practice Address - Phone:719-659-6088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO8331225100000X
MTPTP-PT-LIC-5810225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO533838Medicare ID - Type Unspecified