Provider Demographics
NPI:1518191907
Name:SULLIVAN, THERESE (OTR)
Entity Type:Individual
Prefix:
First Name:THERESE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15802 CEDAR RIDGE CT
Mailing Address - Street 2:
Mailing Address - City:GRANGER
Mailing Address - State:IN
Mailing Address - Zip Code:46530-6516
Mailing Address - Country:US
Mailing Address - Phone:574-243-2487
Mailing Address - Fax:
Practice Address - Street 1:15802 CEDAR RIDGE CT
Practice Address - Street 2:
Practice Address - City:GRANGER
Practice Address - State:IN
Practice Address - Zip Code:46530-6516
Practice Address - Country:US
Practice Address - Phone:574-243-2487
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-13
Last Update Date:2009-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN31004108A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist