Provider Demographics
NPI:1104035260
Name:CULLEN, JOHN PATRICK (MFT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:PATRICK
Last Name:CULLEN
Suffix:
Gender:M
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1658 LOWELL AVE
Mailing Address - Street 2:
Mailing Address - City:CLAREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:91711-3133
Mailing Address - Country:US
Mailing Address - Phone:909-613-7759
Mailing Address - Fax:909-399-5768
Practice Address - Street 1:415 W ROUTE 66
Practice Address - Street 2:202
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-4335
Practice Address - Country:US
Practice Address - Phone:626-963-4467
Practice Address - Fax:626-963-9543
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37329106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist