Provider Demographics
NPI:1679048425
Name:SULLIVAN, SHANNON ELYSE (OTR/L)
Entity Type:Individual
Prefix:
First Name:SHANNON
Middle Name:ELYSE
Last Name:SULLIVAN
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 1:2233 NE 46TH ST APT 202
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98105-5736
Mailing Address - Country:US
Mailing Address - Phone:785-418-9810
Mailing Address - Fax:
Practice Address - Street 1:14715 NE BEL RED RD
Practice Address - Street 2:
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98007-3940
Practice Address - Country:US
Practice Address - Phone:425-502-9440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2018-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60896414225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics