Provider Demographics
NPI:1780090894
Name:SULLIVAN TANSEY, MARY HEATHER (MT)
Entity type:Individual
Prefix:
First Name:MARY HEATHER
Middle Name:
Last Name:SULLIVAN TANSEY
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30138 N 121ST LN
Mailing Address - Street 2:
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85383-3489
Mailing Address - Country:US
Mailing Address - Phone:909-844-1326
Mailing Address - Fax:
Practice Address - Street 1:8996 W UNION HILLS DR
Practice Address - Street 2:#103
Practice Address - City:PEORIA
Practice Address - State:AZ
Practice Address - Zip Code:85382-3010
Practice Address - Country:US
Practice Address - Phone:909-844-1326
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-09
Last Update Date:2014-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ#MT-18093225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist