Individual
TANITA SHANTA SULLIVAN
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Contact information
Practice address
13985 BROKEN ARROW DR, WILLIS, TX 77378-4323
(936) 856-6136
(936) 856-7549
Mailing address
13985 BROKEN ARROW DR, WILLIS, TX 77378-4323
(936) 856-6136
(936) 856-7549
Taxonomy
Speciality
Code
Description
License number
State
320600000X
Intellectual and/or Developmental Disabilities Residential Treatment Facility
Primary
—
—
320700000X
Physical Disabilities Residential Treatment Facility
—
—
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
—
—
324500000X
Substance Abuse Rehabilitation Facility
—
—
Other
Enumeration date
10/29/2010
Last updated
10/29/2010
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