| Doctor Name: | TANITA SHANTA SULLIVAN |
| NPI Number: | 1659671147 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | |
| License Number: | |
| Business Practice Address: | 13985 Broken Arrow Dr Willis, TX - 773784323 |
| Business Phone Number: | 9368566136 |
| Business Fax Number: | 9368567549 |
| Mailing Address: | 13985 Broken Arrow Dr, WILLIS |
| State: | TX |
| Postal Code: | 773784323 |
| Phone Number: | 9368566136 |
| Fax Number: | 9368567549 |
| NPI Enumeration Date: | 10/29/2010 |
| NPI Last Update Date: | 10/29/2010 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 320700000X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | N |
| State: | |
| Taxonomy Type: | Residential Treatment Facilities |
| Taxonomy Classification: | Residential Treatment Facility, Physical Disabilities |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A residential facility that provides habilitation services and other care and treatment to adults or children diagnosed with developmental disabilities and/or mental retardation and are not able to live independently. |