Provider Demographics
NPI:1639108103
Name:SULLIVAN, KIMBERLEE DAWN (DPT)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLEE
Middle Name:DAWN
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12411 HYMEADOW DR
Mailing Address - Street 2:BUILDING 3 SUITE 3B
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78750-1874
Mailing Address - Country:US
Mailing Address - Phone:512-335-9300
Mailing Address - Fax:512-335-9301
Practice Address - Street 1:12411 HYMEADOW DR
Practice Address - Street 2:BUILDING 3 SUITE 3B
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78750-1874
Practice Address - Country:US
Practice Address - Phone:512-335-9300
Practice Address - Fax:512-335-9301
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1151958225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
203156341OtherTAX ID NUMBER