Provider Demographics
NPI:1699361527
Name:CULLUM, STEFANIE NICOLE MARISSA
Entity Type:Individual
Prefix:
First Name:STEFANIE
Middle Name:NICOLE MARISSA
Last Name:CULLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7053 PLACID LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89179-1524
Mailing Address - Country:US
Mailing Address - Phone:702-755-2578
Mailing Address - Fax:
Practice Address - Street 1:2520 SAINT ROSE PKWY STE 306
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NV
Practice Address - Zip Code:89074-7790
Practice Address - Country:US
Practice Address - Phone:702-755-2578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-15
Last Update Date:2020-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty