Provider Demographics
NPI:1144615519
Name:O'SULLIVAN, KELLY (OT)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4812 FIELD LN NW
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98502-8835
Mailing Address - Country:US
Mailing Address - Phone:360-888-7977
Mailing Address - Fax:
Practice Address - Street 1:6530 33RD AVE NW
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98502-8846
Practice Address - Country:US
Practice Address - Phone:360-866-5916
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2015-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOT00002863225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist