Basic Information
| Provider Information | |||||||||
| NPI: | 1366922031 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN | ||||||||
| FirstName: | TINA | ||||||||
| MiddleName: | KAYE | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9156 COUNTY ROAD 309 | ||||||||
| Address2: | |||||||||
| City: | BUFFALO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 758313818 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033917168 | ||||||||
| FaxNumber: | 9033897066 | ||||||||
| Practice Location | |||||||||
| Address1: | 601 E REUNION ST | ||||||||
| Address2: | |||||||||
| City: | FAIRFIELD | ||||||||
| State: | TX | ||||||||
| PostalCode: | 758401634 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033894121 | ||||||||
| FaxNumber: | 9033897066 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2018 | ||||||||
| LastUpdateDate: | 08/21/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2044436 | TX | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.