Provider Demographics
NPI:1841816907
Name:SULLIVAN, EMILY
Entity type:Individual
Prefix:
First Name:EMILY
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4755 FOXBERRY DR
Mailing Address - Street 2:
Mailing Address - City:MEDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55340-4611
Mailing Address - Country:US
Mailing Address - Phone:952-807-2519
Mailing Address - Fax:
Practice Address - Street 1:4755 FOXBERRY DR
Practice Address - Street 2:
Practice Address - City:MEDINA
Practice Address - State:MN
Practice Address - Zip Code:55340-4611
Practice Address - Country:US
Practice Address - Phone:952-807-2519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-24
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN202745224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant