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General NPI Number Information
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NPI Number | 1194462465
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Entity Type | Individual
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Provider Name | MAKENZIE SULLIVAN
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Gender | Female
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Dates
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Enumeration Date | 05/17/2022
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Last Update Date | 05/17/2022
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Provider Practice Location Address
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Address Line | 2612 LONG PRAIRIE RD STE B
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City | FLOWER MOUND
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State | TX
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Zip | 75022-4981
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Country | US
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Telephone | 855-782-7822
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Fax |
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Provider Business Mailing Address
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Address Line | 13861 RACEWAY DR APT 533
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City | NORTHLAKE
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State | TX
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Zip | 76262-6555
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Country | US
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Telephone | 918-978-3198
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 103K00000X
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Taxonomy Name | Behavior Analyst
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License Number | 21-185480
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License Number State | TX
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