Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224Z00000X | Occupational Therapy Assistant | 4930-27 | WI |
NPI | 1023367117 |
---|---|
Provider Name | June Ann Sullivan |
First Address | Fort Atkinson, WI 53538 |
Second Address | Fort Atkinson, WI 53538 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 05/09/2012 |
Last Update Date | 05/09/2012 |