Provider Demographics
NPI:1497914808
Name:SULLIVAN, ALICIA
Entity Type:Individual
Prefix:
First Name:ALICIA
Middle Name:
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 HUNTERS CT
Mailing Address - Street 2:
Mailing Address - City:LAURENS
Mailing Address - State:SC
Mailing Address - Zip Code:29360-2372
Mailing Address - Country:US
Mailing Address - Phone:864-715-9008
Mailing Address - Fax:
Practice Address - Street 1:113 HUNTERS CT
Practice Address - Street 2:
Practice Address - City:LAURENS
Practice Address - State:SC
Practice Address - Zip Code:29360-2372
Practice Address - Country:US
Practice Address - Phone:864-715-9008
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2769224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant