Basic Information
| Provider Information | |||||||||
| NPI: | 1710654967 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | KAITLIN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | OTR/L | ||||||||
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| Mailing Information | |||||||||
| Address1: | 336 AMITYVILLE ST | ||||||||
| Address2: | |||||||||
| City: | ISLIP TERRACE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 117521419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6314878121 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5150 VILLAGE PARK DR SE | ||||||||
| Address2: | |||||||||
| City: | BELLEVUE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980066652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4256570620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2021 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225XP0200X | 61130252 | WA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | Pediatrics |
No ID Information.