Provider Demographics
NPI:1548481971
Name:CULLEN, THOMAS PETER (LCSW-R)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:PETER
Last Name:CULLEN
Suffix:
Gender:M
Credentials:LCSW-R
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 SOUTH CAYUGA ST. #2
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850
Mailing Address - Country:US
Mailing Address - Phone:607-379-2401
Mailing Address - Fax:
Practice Address - Street 1:123 SOUTH CAYUGA ST. #2
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850
Practice Address - Country:US
Practice Address - Phone:607-379-2401
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYR056382-1101YM0800X, 1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYIA1384Medicare UPIN