Provider Demographics
NPI:1316395585
Name:SULLIVAN DEVELOPMENT AND ACTIVITY CENTER
Entity Type:Organization
Organization Name:SULLIVAN DEVELOPMENT AND ACTIVITY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:936-521-1700
Mailing Address - Street 1:13985 BROKEN ARROW DR
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77378-4323
Mailing Address - Country:US
Mailing Address - Phone:936-521-1700
Mailing Address - Fax:855-693-4662
Practice Address - Street 1:15710 BOND LN
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77303-4183
Practice Address - Country:US
Practice Address - Phone:936-521-1700
Practice Address - Fax:855-693-4662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-29
Last Update Date:2016-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No251300000XAgenciesLocal Education Agency (LEA)
No251B00000XAgenciesCase Management
No251C00000XAgenciesDay Training, Developmentally Disabled Services
No385HR2050XRespite Care FacilityRespite CareRespite Care Camp