Provider Demographics
NPI:1891024972
Name:SULLIVAN, SHAWN B (PTA)
Entity Type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:B
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 VILLAGE DR STE 200
Mailing Address - Street 2:
Mailing Address - City:ABILENE
Mailing Address - State:TX
Mailing Address - Zip Code:79606-8232
Mailing Address - Country:US
Mailing Address - Phone:325-691-5519
Mailing Address - Fax:
Practice Address - Street 1:1 VILLAGE DR STE 200
Practice Address - Street 2:
Practice Address - City:ABILENE
Practice Address - State:TX
Practice Address - Zip Code:79606-8232
Practice Address - Country:US
Practice Address - Phone:325-691-5519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-12-18
Last Update Date:2009-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2039113174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist