Provider Demographics
NPI:1154745891
Name:SULLIVAN, ANTONINA ROSARIA (OTR/L)
Entity type:Individual
Prefix:
First Name:ANTONINA
Middle Name:ROSARIA
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 1:23837 ROYAL WORLINGTON DR
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8141
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10350 BRENNER CT
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564
Practice Address - Country:US
Practice Address - Phone:630-664-6488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-18
Last Update Date:2018-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL056010433225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL056010433OtherLICENSE NUMBER