Provider Demographics
NPI:1306037130
Name:O'SULLIVAN, MARY A (MS, OTR/L)
Entity type:Individual
Prefix:MRS
First Name:MARY
Middle Name:A
Last Name:O'SULLIVAN
Suffix:
Gender:F
Credentials:MS, OTR/L
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:A
Other - Last Name:TOMASELLO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:646 E. DELAVAN
Mailing Address - Street 2:ROOM 127
Mailing Address - City:BUFFALO
Mailing Address - State:NY
Mailing Address - Zip Code:14215
Mailing Address - Country:US
Mailing Address - Phone:716-816-4174
Mailing Address - Fax:941-359-1555
Practice Address - Street 1:646 E. DELAVAN
Practice Address - Street 2:ROOM 127
Practice Address - City:BUFFALO
Practice Address - State:NY
Practice Address - Zip Code:14215
Practice Address - Country:US
Practice Address - Phone:716-816-4174
Practice Address - Fax:941-359-1555
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2024-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOT 12835225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000385100Medicaid
FL892350700Medicaid