Provider Demographics
NPI:1366922031
Name:SULLIVAN, TINA KAYE (PTA)
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:KAYE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9156 COUNTY ROAD 309
Mailing Address - Street 2:
Mailing Address - City:BUFFALO
Mailing Address - State:TX
Mailing Address - Zip Code:75831-3818
Mailing Address - Country:US
Mailing Address - Phone:903-391-7168
Mailing Address - Fax:903-389-7066
Practice Address - Street 1:601 E REUNION ST
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:TX
Practice Address - Zip Code:75840-1634
Practice Address - Country:US
Practice Address - Phone:903-389-4121
Practice Address - Fax:903-389-7066
Is Sole Proprietor?:No
Enumeration Date:2018-08-21
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2044436225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant