Provider Demographics
NPI:1598356768
Name:SULLIVAN, TATIANA
Entity Type:Individual
Prefix:
First Name:TATIANA
Middle Name:
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 1:2221 SAW PALMETTO PLACE APT 24-102
Mailing Address - Street 2:
Mailing Address - City:LAND O LAKES
Mailing Address - State:FL
Mailing Address - Zip Code:34639
Mailing Address - Country:US
Mailing Address - Phone:863-243-9358
Mailing Address - Fax:
Practice Address - Street 1:9550 US HIGHWAY 19 SUITE 202
Practice Address - Street 2:
Practice Address - City:PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34668
Practice Address - Country:US
Practice Address - Phone:727-494-7609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-01
Last Update Date:2021-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health