Provider Demographics
NPI:1124189394
Name:SULLIVAN, MOIRA (MS, OTR/L)
Entity Type:Individual
Prefix:
First Name:MOIRA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2066 CLARMAR WAY STE A
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95128-1715
Mailing Address - Country:US
Mailing Address - Phone:408-280-7712
Mailing Address - Fax:408-280-7721
Practice Address - Street 1:2066 CLARMAR WAY STE A
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95128-1715
Practice Address - Country:US
Practice Address - Phone:408-280-7712
Practice Address - Fax:408-280-7721
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA3384225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist