Provider Demographics
NPI:1033253885
Name:CULLEN, SANDRA MARY (LICDC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MARY
Last Name:CULLEN
Suffix:
Gender:F
Credentials:LICDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7251 JETHVE LN
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45243-2112
Mailing Address - Country:US
Mailing Address - Phone:513-509-6924
Mailing Address - Fax:
Practice Address - Street 1:7654 MONTGOMERY RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45236-4204
Practice Address - Country:US
Practice Address - Phone:513-600-1416
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH001418101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)