Provider Demographics
NPI:1437377199
Name:SULLIVAN PHYSICAL THERAPY LLC
Entity Type:Organization
Organization Name:SULLIVAN PHYSICAL THERAPY LLC
Other - Org Name:KIMBERLEE D SULLIVAN DPT
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER & PHYSICAL THERAPIST
Authorized Official - Prefix:DR
Authorized Official - First Name:KIMBERLEE
Authorized Official - Middle Name:D
Authorized Official - Last Name:SULLIVAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPT
Authorized Official - Phone:512-335-9300
Mailing Address - Street 1:1321 UPLAND DR.
Mailing Address - Street 2:PMB 19899
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77043
Mailing Address - Country:US
Mailing Address - Phone:512-335-9300
Mailing Address - Fax:512-335-9301
Practice Address - Street 1:12411 HYMEADOW DR STE 3B
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1829
Practice Address - Country:US
Practice Address - Phone:512-335-9300
Practice Address - Fax:512-335-9301
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-20
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1151958225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX659678OtherBCBS OF TX PROVIDER NUMBE
TX659678OtherBCBS OF TX PROVIDER NUMBE
TXP00367706Medicare ID - Type UnspecifiedRAILROAD MEDICARE PROVIDE