Provider Demographics
NPI:1770348815
Name:CULLISON, MOLLY ELIZABETH
Entity type:Individual
Prefix:
First Name:MOLLY
Middle Name:ELIZABETH
Last Name:CULLISON
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 1:5650 GRISSOM RD APT 2105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78238-2255
Mailing Address - Country:US
Mailing Address - Phone:210-973-0881
Mailing Address - Fax:
Practice Address - Street 1:121 INTERPARK BLVD STE 104
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78216-1844
Practice Address - Country:US
Practice Address - Phone:726-201-3081
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-19
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXRBT22244831106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician