Provider Demographics
NPI:1639213986
Name:SULLIVAN, DONALD CHAD (OTRL)
Entity Type:Individual
Prefix:
First Name:DONALD
Middle Name:CHAD
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:OTRL
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1650 KENSINGTON PL
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-1159
Mailing Address - Country:US
Mailing Address - Phone:479-283-0024
Mailing Address - Fax:
Practice Address - Street 1:1650 KENSINGTON PL
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-1159
Practice Address - Country:US
Practice Address - Phone:479-283-0024
Practice Address - Fax:636-444-8533
Is Sole Proprietor?:No
Enumeration Date:2007-02-19
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR1114225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR132983721Medicaid