Basic Information
| Provider Information | |||||||||
| NPI: | 1598350456 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CULLEN | ||||||||
| FirstName: | TIA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PTA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | HAYES | ||||||||
| OtherFirstName: | TIA | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 721018 | ||||||||
| Address2: | |||||||||
| City: | NORMAN | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730704786 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4058098713 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1486 S ELLIOTT ST | ||||||||
| Address2: | |||||||||
| City: | PRYOR | ||||||||
| State: | OK | ||||||||
| PostalCode: | 743618002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9188252333 | ||||||||
| FaxNumber: | 9188256266 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/03/2021 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | 2183 | OK | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.