Provider Demographics
NPI:1073106050
Name:SULLIVAN, JANET DIANE
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:DIANE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2509 CLAUDIA DR
Mailing Address - Street 2:
Mailing Address - City:LEANDER
Mailing Address - State:TX
Mailing Address - Zip Code:78641-3076
Mailing Address - Country:US
Mailing Address - Phone:505-377-6339
Mailing Address - Fax:
Practice Address - Street 1:3405 EL SALIDO PKWY
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-5640
Practice Address - Country:US
Practice Address - Phone:512-402-5040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-19
Last Update Date:2021-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX205168224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant