Provider Demographics
NPI:1598958167
Name:SULLIVAN, ELIZABETH MARIE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:MARIE
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 1:1000 EDDY ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905-4739
Mailing Address - Country:US
Mailing Address - Phone:401-533-9100
Mailing Address - Fax:
Practice Address - Street 1:1000 EDDY ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-4739
Practice Address - Country:US
Practice Address - Phone:401-533-9100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-27
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIOT01159225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI292177OtherEI BCROSS
RI412296OtherEI BCHIP
RI6400144OtherUNITED
RI99947OtherBCROSS
RI2058OtherNHPRC
RI2092OtherEI NHPRC
RI9009994Medicaid
RIES01788Medicaid
RI6400144OtherEI UNITED