Provider Demographics
NPI:1881244069
Name:CULZAC, SHAVONE L
Entity type:Individual
Prefix:
First Name:SHAVONE
Middle Name:L
Last Name:CULZAC
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 1:7613 STANDISH PL
Mailing Address - Street 2:
Mailing Address - City:DERWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:20855-2702
Mailing Address - Country:US
Mailing Address - Phone:240-672-0330
Mailing Address - Fax:
Practice Address - Street 1:21600 OXNARD ST STE 1800
Practice Address - Street 2:
Practice Address - City:WOODLAND HILLS
Practice Address - State:CA
Practice Address - Zip Code:91367-7807
Practice Address - Country:US
Practice Address - Phone:818-345-2345
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDCDC3773106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician