MEDICARE: MRS. MARILYN J CULLUM LPC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP2500X	Professional Counselor	P9807016	AR

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	5U425	OTHER	AR	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1730245465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MARILYN J CULLUM LPC

Provider Business Mailing Address
First Line	:	139 COUNTY ROAD 395
Second Line	:
City	:	WYNNE
State	:	AR
Zip	:	72396
Country	:	US
Telephone Number	:	870-238-5596
Fax Number	:	870-208-9229

Provider Business Practice Location Address
First Line	:	1742 FALLS BLVD. SUITE 5
Second Line	:	THE LOGAN CENTER
City	:	WYNNE
State	:	AR
Zip	:	72396
Country	:	US
Telephone Number	:	870-208-9333
Fax Number	:	870-208-9229

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/28/2006
Last Update Date	:	07/08/2007

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