Healthcare Provider Details

I. General information

NPI: 1558904557
Provider Name (Legal Business Name): CULLEN JOHNSON ROTH RSPS, MHPS, PSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 01/28/2024
Certification Date: 01/28/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12301 MAIN ST
HOUSTON TX
77035-6207
US

IV. Provider business mailing address

PO BOX 524132
HOUSTON TX
77052-4132
US

V. Phone/Fax

Practice location:
  • Phone: 713-275-5115
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number1271-0621
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number50028-0820
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: