Provider Demographics
NPI:1164648895
Name:CULLINS, JOANNA MARIE (PSYD)
Entity Type:Individual
Prefix:DR
First Name:JOANNA
Middle Name:MARIE
Last Name:CULLINS
Suffix:
Gender:F
Credentials:PSYD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 MAIN ST UNIT 111
Mailing Address - Street 2:
Mailing Address - City:FOREST GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97116-3240
Mailing Address - Country:US
Mailing Address - Phone:503-894-2725
Mailing Address - Fax:360-325-4358
Practice Address - Street 1:4400 NE 77TH AVE STE 275
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98662-6857
Practice Address - Country:US
Practice Address - Phone:503-894-2725
Practice Address - Fax:360-326-2255
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2021-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPY60482905103TC0700X
OR2393103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR164936Medicaid