Provider Demographics
NPI:1881600054
Name:SULLIVAN, MILISSA LYNN (OTRL)
Entity type:Individual
Prefix:MRS
First Name:MILISSA
Middle Name:LYNN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OTRL
Other - Prefix:MS
Other - First Name:MILISSA
Other - Middle Name:
Other - Last Name:PELFREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OTRL
Mailing Address - Street 1:PO BOX 911148
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40591-1148
Mailing Address - Country:US
Mailing Address - Phone:859-278-2121
Mailing Address - Fax:
Practice Address - Street 1:118 S MAIN ST
Practice Address - Street 2:
Practice Address - City:DRY RIDGE
Practice Address - State:KY
Practice Address - Zip Code:41035
Practice Address - Country:US
Practice Address - Phone:859-824-7007
Practice Address - Fax:859-824-7077
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYR0951225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist