Healthcare Provider Details

I. General information

NPI: 1144149717
Provider Name (Legal Business Name): GRACIE JAI SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2026
Last Update Date: 07/15/2026
Certification Date: 07/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3111 N MICHIGAN ST
PITTSBURG KS
66762-2545
US

IV. Provider business mailing address

3143 KAPOK DR
SENECA MO
64865-8438
US

V. Phone/Fax

Practice location:
  • Phone: 620-230-9754
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: