Provider Demographics
NPI:1073972436
Name:SULLIVAN, SHAWNA (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHAWNA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:799 W BOYLSTON ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01606-3071
Mailing Address - Country:US
Mailing Address - Phone:774-314-5393
Mailing Address - Fax:
Practice Address - Street 1:799 W BOYLSTON ST
Practice Address - Street 2:
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01606-3071
Practice Address - Country:US
Practice Address - Phone:774-314-5393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-14
Last Update Date:2016-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA10176225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist