MEDICARE: SULLIVAN DEVELOPMENT AND ACTIVITY CENTER, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy
1	251C00000X	Developmentally Disabled Services Day Training Agency
2	385HR2050X	Respite Care Camp
3	251300000X	Local Education Agency (LEA)
4	251B00000X	Case Management Agency
5	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1316395585
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SULLIVAN DEVELOPMENT AND ACTIVITY CENTER, INC.

Provider Business Mailing Address
First Line	:	13985 BROKEN ARROW DR
Second Line	:
City	:	WILLIS
State	:	TX
Zip	:	77378-4323
Country	:	US
Telephone Number	:	832-549-1364
Fax Number	:	855-693-4662

Provider Business Practice Location Address
First Line	:	15710 BOND LN
Second Line	:
City	:	CONROE
State	:	TX
Zip	:	77303-4183
Country	:	US
Telephone Number	:	936-521-1700
Fax Number	:	855-693-4662

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. TANITA SULLIVAN
Credential	:
Telephone Number	:	936-521-1700

Provider Enumeration Date	:	05/29/2016
Last Update Date	:	05/16/2026

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