Provider Demographics
NPI:1942817895
Name:SULLIVAN, THAXTON
Entity Type:Individual
Prefix:
First Name:THAXTON
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 COURTLAND DR APT 50
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8186
Mailing Address - Country:US
Mailing Address - Phone:601-422-7472
Mailing Address - Fax:
Practice Address - Street 1:572 ESSAYONS DR.
Practice Address - Street 2:92ND ENGINEER BN
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-3131
Practice Address - Country:US
Practice Address - Phone:601-422-7472
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-24
Last Update Date:2023-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
TXAT91202255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer