Healthcare Provider Details

I. General information

NPI: 1992007215
Provider Name (Legal Business Name): CARRIE MARIE SULLIVAN MSOTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2010
Last Update Date: 11/18/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1356 UNIVERSITY AVE
BERKELEY CA
94702-1711
US

IV. Provider business mailing address

841 COLLIER DR
SAN LEANDRO CA
94577-3817
US

V. Phone/Fax

Practice location:
  • Phone: 510-845-5537
  • Fax:
Mailing address:
  • Phone: 510-483-2832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225XN1300X
TaxonomyNeurorehabilitation Occupational Therapist
License NumberOT5695
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: