Provider Demographics
NPI:1053892281
Name:CULLUM, FELISHA (MA)
Entity type:Individual
Prefix:
First Name:FELISHA
Middle Name:
Last Name:CULLUM
Suffix:
Gender:F
Credentials:MA
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 1916
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-0036
Mailing Address - Country:US
Mailing Address - Phone:760-900-2911
Mailing Address - Fax:
Practice Address - Street 1:14420 CIVIC DR STE 4
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2384
Practice Address - Country:US
Practice Address - Phone:760-490-0109
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-25
Last Update Date:2018-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA80743106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist