MEDICARE: ANGELA SULLIVAN M.S., OTR/L

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225X00000X	Occupational Therapist	OC006729L	PA

General Provider Information

NPI Number	:	1023240660
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA SULLIVAN M.S., OTR/L

Provider Business Mailing Address
First Line	:	163 HONEY POT ST REAR
Second Line	:
City	:	NANTICOKE
State	:	PA
Zip	:	18634-1541
Country	:	US
Telephone Number	:	570-735-4071
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 HAZLE TOWNSHIP BLVD # 403
Second Line	:
City	:	HAZLE TOWNSHIP
State	:	PA
Zip	:	18202-9661
Country	:	US
Telephone Number	:	570-454-8888
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2009
Last Update Date	:	04/30/2021

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