Provider Demographics
NPI:1992007215
Name:SULLIVAN, CARRIE MARIE (MSOTR/L)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:MARIE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:MSOTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:841 COLLIER DR
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-3817
Mailing Address - Country:US
Mailing Address - Phone:510-483-2832
Mailing Address - Fax:
Practice Address - Street 1:1356 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94702-1711
Practice Address - Country:US
Practice Address - Phone:510-845-5537
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-11-18
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOT5695225XN1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XN1300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistNeurorehabilitation