Provider Demographics
NPI:1023797446
Name:SULLIVAN, REBECCA (COTA/L)
Entity type:Individual
Prefix:
First Name:REBECCA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:COTA/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1193 MIDVALE AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-5211
Mailing Address - Country:US
Mailing Address - Phone:843-337-8811
Mailing Address - Fax:
Practice Address - Street 1:1563 SAM RITTENBERG BLVD
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29407-4248
Practice Address - Country:US
Practice Address - Phone:843-337-8811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-13
Last Update Date:2023-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2658224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant