MEDICARE: AMANDA SULLIVAN OTR

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	08428	MD

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386207462
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AMANDA SULLIVAN OTR

Provider Business Mailing Address
First Line	:	109 WOODBROOK LN
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21212-1035
Country	:	US
Telephone Number	:	908-216-3193
Fax Number	:	214-305-3399

Provider Business Practice Location Address
First Line	:	6811 CAMPFIELD RD
Second Line	:
City	:	BALTIMORE
State	:	MD
Zip	:	21207-4657
Country	:	US
Telephone Number	:	410-486-4573
Fax Number	:	443-471-0105

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

Provider Enumeration Date	:	04/15/2019
Last Update Date	:	04/15/2019

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Directions to “ AMANDA SULLIVAN OTR” Practice Location

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