MEDICARE: LEAH MARIE FOREMAN SULLIVAN

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	OT.0006288	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	OT.0006288	OTHER	CO	COLORADO OTR LICENSE

General Provider Information

NPI Number	:	1366072522
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LEAH MARIE FOREMAN SULLIVAN

Provider Business Mailing Address
First Line	:	1945 OWENS CT
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80215-2732
Country	:	US
Telephone Number	:	614-381-1382
Fax Number	:	720-316-6020

Provider Business Practice Location Address
First Line	:	1945 OWENS CT
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80215-2732
Country	:	US
Telephone Number	:	614-381-1382
Fax Number	:	720-316-6020

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

Provider Enumeration Date	:	01/16/2020
Last Update Date	:	12/15/2020

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