Provider Demographics
NPI:1609810720
Name:SULLIVAN, JOANNE DAMIN (PT)
Entity type:Individual
Prefix:
First Name:JOANNE
Middle Name:DAMIN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:31 OLD ROUTE 7
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06804-1714
Mailing Address - Country:US
Mailing Address - Phone:203-740-0020
Mailing Address - Fax:203-775-0238
Practice Address - Street 1:90 GROVE ST
Practice Address - Street 2:SUITE 106
Practice Address - City:RIDGEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06877-4114
Practice Address - Country:US
Practice Address - Phone:203-431-8471
Practice Address - Fax:203-438-9543
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002634225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004210217Medicaid
CT080002634CT01OtherANTHEM BC
CT004210217Medicaid