Healthcare Provider Details

I. General information

NPI: 1609793819
Provider Name (Legal Business Name): EMMA FAUSTINA SULLIVAN OTR/L
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 FORBES RD
BRAINTREE MA
02184-2705
US

IV. Provider business mailing address

114 BROOK ST
BROOKLINE MA
02445-7186
US

V. Phone/Fax

Practice location:
  • Phone: 617-322-2694
  • Fax:
Mailing address:
  • Phone: 603-716-4031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberOTL36315
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: