Provider Demographics
NPI:1023479839
Name:SULLIVAN, KEVIN (MOTR-L)
Entity type:Individual
Prefix:
First Name:KEVIN
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:MOTR-L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10307 NIGHTWIND CIR
Mailing Address - Street 2:
Mailing Address - City:CANTONMENT
Mailing Address - State:FL
Mailing Address - Zip Code:32533-6651
Mailing Address - Country:US
Mailing Address - Phone:505-710-2587
Mailing Address - Fax:
Practice Address - Street 1:8325 UNIVERSITY PKWY
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-4949
Practice Address - Country:US
Practice Address - Phone:850-898-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-08
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM3498225XP0200X
FL19447225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM10171568Medicaid
NM326556OtherMEDICARE