Provider Demographics
NPI:1770729436
Name:SULLIVAN, ELLEN BRISTOL (OTR/L)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:BRISTOL
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:ELLEN
Other - Middle Name:CAROL
Other - Last Name:BRISTOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:892 WEST RD
Mailing Address - Street 2:
Mailing Address - City:ASHBY
Mailing Address - State:MA
Mailing Address - Zip Code:01431-1745
Mailing Address - Country:US
Mailing Address - Phone:978-386-0285
Mailing Address - Fax:
Practice Address - Street 1:100 ERDMAN WAY
Practice Address - Street 2:LIPTON CENTER EARLY INTERVENTION
Practice Address - City:LEOMINSTER
Practice Address - State:MA
Practice Address - Zip Code:01453-1804
Practice Address - Country:US
Practice Address - Phone:978-840-9354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-31
Last Update Date:2008-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA6977225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist