Individual
KELLY ELIZABETH SULLIVAN
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
COTA
Contact information
Practice address
12 DEFOREST RD, LANSDOWNE, PA 19050-2109
(610) 653-3204
Mailing address
12 DEFOREST RD, LANSDOWNE, PA 19050-2109
(610) 653-3204
Taxonomy
Speciality
Code
Description
License number
State
224Z00000X
Occupational Therapy Assistant
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
28417300
DRIVERS LICENSE
PA
Enumeration date
07/12/2019
Last updated
07/12/2019
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