Provider Demographics
NPI:1760887715
Name:SULLIVAN, CASEY ELIZABETH (OTR/L)
Entity Type:Individual
Prefix:
First Name:CASEY
Middle Name:ELIZABETH
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 1:2545 24TH ST
Mailing Address - Street 2:
Mailing Address - City:ROCK ISLAND
Mailing Address - State:IL
Mailing Address - Zip Code:61201-5305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2545 24TH ST
Practice Address - Street 2:
Practice Address - City:ROCK ISLAND
Practice Address - State:IL
Practice Address - Zip Code:61201-5305
Practice Address - Country:US
Practice Address - Phone:309-788-0458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-01
Last Update Date:2014-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010748225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056010748OtherIL OCCUPATIONAL THERAPY LICENSE NUMBER
330341OtherNBCOT