MEDICARE: SHANNON TOBI CULLER MA CCC-SLP

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	235Z00000X	Speech-Language Pathologist	2903	OK

General Provider Information

NPI Number	:	1821231994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHANNON TOBI CULLER MA CCC-SLP

Provider Business Mailing Address
First Line	:	2809 W HOUSTON PLACE
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012
Country	:	US
Telephone Number	:	918-671-4121
Fax Number	:

Provider Business Practice Location Address
First Line	:	2809 W HOUSTON PL
Second Line	:
City	:	BROKEN ARROW
State	:	OK
Zip	:	74012-3259
Country	:	US
Telephone Number	:	918-671-4121
Fax Number	:

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

Provider Enumeration Date	:	04/19/2009
Last Update Date	:	04/19/2009

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