Provider Demographics
NPI:1811282254
Name:CULLUM, REGAN
Entity type:Individual
Prefix:
First Name:REGAN
Middle Name:
Last Name:CULLUM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:REGAN
Other - Middle Name:
Other - Last Name:HARRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 SKYLINE DR
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72801-3362
Mailing Address - Country:US
Mailing Address - Phone:479-967-5570
Mailing Address - Fax:501-354-1564
Practice Address - Street 1:8 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MORRILTON
Practice Address - State:AR
Practice Address - Zip Code:72110
Practice Address - Country:US
Practice Address - Phone:501-354-1561
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-14
Last Update Date:2023-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
ARPLMSW104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR218156795Medicaid