Provider Demographics
NPI:1063006997
Name:SULLIVAN, LISA MARIE
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:113 MITCHELL BLVD
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:OH
Mailing Address - Zip Code:45030-2197
Mailing Address - Country:US
Mailing Address - Phone:513-205-9732
Mailing Address - Fax:
Practice Address - Street 1:4320 BRIDGETOWN RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45211-4428
Practice Address - Country:US
Practice Address - Phone:513-574-4550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-22
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOT007496225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist