Provider Demographics
NPI:1598350456
Name:CULLEN, TIA R (PTA)
Entity Type:Individual
Prefix:
First Name:TIA
Middle Name:R
Last Name:CULLEN
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:TIA
Other - Middle Name:
Other - Last Name:HAYES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 721018
Mailing Address - Street 2:
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73070-4786
Mailing Address - Country:US
Mailing Address - Phone:405-809-8713
Mailing Address - Fax:
Practice Address - Street 1:1486 S ELLIOTT ST
Practice Address - Street 2:
Practice Address - City:PRYOR
Practice Address - State:OK
Practice Address - Zip Code:74361-8002
Practice Address - Country:US
Practice Address - Phone:918-825-2333
Practice Address - Fax:918-825-6266
Is Sole Proprietor?:No
Enumeration Date:2021-03-03
Last Update Date:2021-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2183225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant