Provider Demographics
NPI:1801231154
Name:MCCULLOCH, SHAUNA LEA (LAC)
Entity Type:Individual
Prefix:
First Name:SHAUNA
Middle Name:LEA
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:SHAUNA
Other - Middle Name:LEA
Other - Last Name:OHARA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:5 PROSPECT AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-5130
Mailing Address - Country:US
Mailing Address - Phone:415-518-3925
Mailing Address - Fax:
Practice Address - Street 1:605 CHENERY ST
Practice Address - Street 2:STE.C
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94131-3033
Practice Address - Country:US
Practice Address - Phone:415-585-1990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-30
Last Update Date:2013-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 14867171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist