Provider Demographics
NPI:1104229723
Name:SULLIVAN, KARA ELISABETH (OTR/L)
Entity type:Individual
Prefix:MS
First Name:KARA
Middle Name:ELISABETH
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 1:40 MONTCALM AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:BRIGHTON
Mailing Address - State:MA
Mailing Address - Zip Code:02135-2841
Mailing Address - Country:US
Mailing Address - Phone:774-291-1301
Mailing Address - Fax:
Practice Address - Street 1:40 MONTCALM AVE UNIT 1
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MA
Practice Address - Zip Code:02135
Practice Address - Country:US
Practice Address - Phone:774-291-1301
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-28
Last Update Date:2018-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
MA12075225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
No174400000XOther Service ProvidersSpecialist