Provider Demographics
NPI:1003670944
Name:KULL, SHANTARA
Entity Type:Individual
Prefix:MRS
First Name:SHANTARA
Middle Name:
Last Name:KULL
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 1:401 DANVERS RIVER STREET
Mailing Address - Street 2:318
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036
Mailing Address - Country:US
Mailing Address - Phone:805-616-3059
Mailing Address - Fax:
Practice Address - Street 1:401 DANVERS RIVER STREET
Practice Address - Street 2:318
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036
Practice Address - Country:US
Practice Address - Phone:805-616-3059
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-12
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health