Provider Demographics
NPI:1760283816
Name:SULLIVAN, OTHRESSA (CRANIAL PROTHESIS SP)
Entity type:Individual
Prefix:MS
First Name:OTHRESSA
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:
Credentials:CRANIAL PROTHESIS SP
Other - Prefix:MS
Other - First Name:OTHRESSA
Other - Middle Name:
Other - Last Name:SULLIVAN
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:15606 WOODLAWN EAST AVE
Mailing Address - Street 2:
Mailing Address - City:SOUTH HOLLAND
Mailing Address - State:IL
Mailing Address - Zip Code:60473-1834
Mailing Address - Country:US
Mailing Address - Phone:630-251-3838
Mailing Address - Fax:
Practice Address - Street 1:15606 WOODLAWN EAST AVE
Practice Address - Street 2:
Practice Address - City:SOUTH HOLLAND
Practice Address - State:IL
Practice Address - Zip Code:60473-1834
Practice Address - Country:US
Practice Address - Phone:630-251-3838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier