Healthcare Provider Details

I. General information

NPI: 1023963196
Provider Name (Legal Business Name): SHAKEIRA SULLIVAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2026
Last Update Date: 03/03/2026
Certification Date: 03/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 GLENN AVE
EGG HARBOR TOWNSHIP NJ
08234-6109
US

IV. Provider business mailing address

1334 DREXEL AVE
ATLANTIC CITY NJ
08401-3203
US

V. Phone/Fax

Practice location:
  • Phone: 877-504-4141
  • Fax:
Mailing address:
  • Phone: 619-373-5034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number106S00000X
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: