Provider Demographics
NPI:1003027772
Name:MCCULLOM, TANYA
Entity Type:Individual
Prefix:
First Name:TANYA
Middle Name:
Last Name:MCCULLOM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 BANCROFT AVE
Mailing Address - Street 2:SUITE 125D
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94605-2403
Mailing Address - Country:US
Mailing Address - Phone:510-777-3886
Mailing Address - Fax:510-777-3880
Practice Address - Street 1:7200 BANCROFT AVE
Practice Address - Street 2:SUITE 125D
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94605-2403
Practice Address - Country:US
Practice Address - Phone:510-777-3886
Practice Address - Fax:510-777-3880
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator