Provider Demographics
NPI:1659671147
Name:SULLIVAN, TANITA SHANTA
Entity type:Individual
Prefix:
First Name:TANITA
Middle Name:SHANTA
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 1:13985 BROKEN ARROW DR
Mailing Address - Street 2:
Mailing Address - City:WILLIS
Mailing Address - State:TX
Mailing Address - Zip Code:77378-4323
Mailing Address - Country:US
Mailing Address - Phone:936-856-6136
Mailing Address - Fax:936-856-7549
Practice Address - Street 1:13985 BROKEN ARROW DR
Practice Address - Street 2:
Practice Address - City:WILLIS
Practice Address - State:TX
Practice Address - Zip Code:77378-4323
Practice Address - Country:US
Practice Address - Phone:936-856-6136
Practice Address - Fax:936-856-7549
Is Sole Proprietor?:Yes
Enumeration Date:2010-10-29
Last Update Date:2010-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility