Provider Demographics
NPI:1417589458
Name:MCCULLEN, STEPHANNIE
Entity Type:Individual
Prefix:
First Name:STEPHANNIE
Middle Name:
Last Name:MCCULLEN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:STEPHANNIE
Other - Middle Name:
Other - Last Name:TAMAYO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3681 GREEN RD STE 404
Mailing Address - Street 2:
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122-5716
Mailing Address - Country:US
Mailing Address - Phone:434-282-8414
Mailing Address - Fax:484-884-0628
Practice Address - Street 1:35010 CHARDON RD STE 200
Practice Address - Street 2:
Practice Address - City:WILLOUGHBY HILLS
Practice Address - State:OH
Practice Address - Zip Code:44094-9011
Practice Address - Country:US
Practice Address - Phone:216-342-5484
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-07
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW0228591041C0700X
OHI.23045411041C0700X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PACW022859OtherSTATE LICENSE