Basic Information
| Provider Information | |||||||||
| NPI: | 1104035260 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CULLEN | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | MFT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1658 LOWELL AVE | ||||||||
| Address2: | |||||||||
| City: | CLAREMONT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917113133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9096137759 | ||||||||
| FaxNumber: | 9093995768 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 W ROUTE 66 | ||||||||
| Address2: | 202 | ||||||||
| City: | GLENDORA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917404335 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6269634467 | ||||||||
| FaxNumber: | 6269639543 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/22/2007 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 37329 | CA | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.