Provider Demographics
NPI:1366673592
Name:SULLIVAN, TINA J (OTR/L)
Entity type:Individual
Prefix:MS
First Name:TINA
Middle Name:J
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3314 PEARL STREET
Mailing Address - Street 2:
Mailing Address - City:PORT LEYDEN
Mailing Address - State:NY
Mailing Address - Zip Code:13433-0066
Mailing Address - Country:US
Mailing Address - Phone:315-348-8160
Mailing Address - Fax:
Practice Address - Street 1:3314 PEARL ST.
Practice Address - Street 2:
Practice Address - City:PORT LEYDEN
Practice Address - State:NY
Practice Address - Zip Code:13433-0066
Practice Address - Country:US
Practice Address - Phone:315-348-8160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-05
Last Update Date:2009-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008117172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker