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General NPI Number Information
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NPI Number | 1366922031
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Entity Type | Individual
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Provider Name | TINA KAYE SULLIVAN PTA
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Gender | Female
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Dates
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Enumeration Date | 08/21/2018
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Last Update Date | 08/21/2018
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Provider Practice Location Address
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Address Line | 601 E REUNION ST
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City | FAIRFIELD
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State | TX
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Zip | 75840-1634
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Country | US
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Telephone | 903-389-4121
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Fax | 903-389-7066
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Provider Business Mailing Address
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Address Line | 9156 COUNTY ROAD 309
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City | BUFFALO
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State | TX
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Zip | 75831-3818
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Country | US
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Telephone | 903-391-7168
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Fax | 903-389-7066
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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 | 225200000X
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Taxonomy Name | Physical Therapy Assistant
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License Number | 2044436
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License Number State | TX
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