Healthcare Provider Details

I. General information

NPI: 1023673233
Provider Name (Legal Business Name): SHANE CULLEN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/02/2019
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2775 STATE ROUTE 39
SHELBY OH
44875-9466
US

IV. Provider business mailing address

2775 STATE ROUTE 39
SHELBY OH
44875-9466
US

V. Phone/Fax

Practice location:
  • Phone: 419-747-3322
  • Fax:
Mailing address:
  • Phone: 419-747-3322
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberCDCA.170130
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: