Provider Demographics
NPI:1720194533
Name:CULLISON, KATHRYN R (MA, MFT)
Entity Type:Individual
Prefix:
First Name:KATHRYN
Middle Name:R
Last Name:CULLISON
Suffix:
Gender:F
Credentials:MA, MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 405
Mailing Address - Street 2:
Mailing Address - City:YREKA
Mailing Address - State:CA
Mailing Address - Zip Code:96097-0405
Mailing Address - Country:US
Mailing Address - Phone:530-842-9668
Mailing Address - Fax:530-842-9668
Practice Address - Street 1:304 YAMA ST
Practice Address - Street 2:
Practice Address - City:YREKA
Practice Address - State:CA
Practice Address - Zip Code:96097-2418
Practice Address - Country:US
Practice Address - Phone:530-842-9668
Practice Address - Fax:530-842-9668
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-22
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMFC30628106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist