Provider Demographics
NPI:1386289346
Name:SULLIVAN, GABRIELLE
Entity type:Individual
Prefix:
First Name:GABRIELLE
Middle Name:
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5209 DUVAL RD
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78727-6614
Mailing Address - Country:US
Mailing Address - Phone:512-250-5700
Mailing Address - Fax:
Practice Address - Street 1:5209 DUVAL RD
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78727-6614
Practice Address - Country:US
Practice Address - Phone:512-250-5700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-14
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT-18-58539106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician