Provider Demographics
NPI:1720404338
Name:GITHAIGA, SALLY
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:GITHAIGA
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 1:14501 MONTFORT DR APT 933
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75254-8589
Mailing Address - Country:US
Mailing Address - Phone:214-527-7914
Mailing Address - Fax:
Practice Address - Street 1:11734 FERGUSON RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75228-8202
Practice Address - Country:US
Practice Address - Phone:214-527-7914
Practice Address - Fax:972-686-1052
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-07
Last Update Date:2014-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities