Provider Demographics
NPI:1619623899
Name:OSULLIVAN, MADISON NICHOLE (OTR/L)
Entity Type:Individual
Prefix:
First Name:MADISON
Middle Name:NICHOLE
Last Name:OSULLIVAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6741 BROMWICH LN APT 301
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-5284
Mailing Address - Country:US
Mailing Address - Phone:910-787-8513
Mailing Address - Fax:
Practice Address - Street 1:54 RED MULBERRY WAY
Practice Address - Street 2:
Practice Address - City:LILLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27546-9633
Practice Address - Country:US
Practice Address - Phone:910-814-8030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-25
Last Update Date:2022-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC14824225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist