Provider Demographics
NPI:1295757698
Name:SULLIVAN, TERRI (OT)
Entity type:Individual
Prefix:
First Name:TERRI
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 N 9TH ST
Mailing Address - Street 2:
Mailing Address - City:BISMARCK
Mailing Address - State:ND
Mailing Address - Zip Code:58501-4508
Mailing Address - Country:US
Mailing Address - Phone:701-530-8800
Mailing Address - Fax:701-530-8763
Practice Address - Street 1:310 N 9TH ST
Practice Address - Street 2:
Practice Address - City:BISMARCK
Practice Address - State:ND
Practice Address - Zip Code:58501-4508
Practice Address - Country:US
Practice Address - Phone:701-530-8800
Practice Address - Fax:701-530-8763
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND371225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND54921Medicaid
ND24286Medicare ID - Type UnspecifiedND MEDICARE