Healthcare Provider Details

I. General information

NPI: 1932475712
Provider Name (Legal Business Name): KELLY SULLIVAN, OTR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2012
Last Update Date: 03/27/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

444 W KENWOOD DR
LOUISVILLE KY
40214-2859
US

IV. Provider business mailing address

444 W KENWOOD DR
LOUISVILLE KY
40214-2859
US

V. Phone/Fax

Practice location:
  • Phone: 502-396-1472
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License NumberKY-R2746
License Number StateKY

VIII. Authorized Official

Name: KELLY SULLIVAN
Title or Position: OWNER
Credential:
Phone: 502-396-1472