Provider Demographics
NPI:1730211715
Name:CULLEN-CARROLL, SHANNA (MFT)
Entity type:Individual
Prefix:MISS
First Name:SHANNA
Middle Name:
Last Name:CULLEN-CARROLL
Suffix:
Gender:F
Credentials:MFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 SUN AVE NE
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87109-4659
Mailing Address - Country:US
Mailing Address - Phone:505-376-9077
Mailing Address - Fax:
Practice Address - Street 1:100 SUN AVE NE STE 650
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4670
Practice Address - Country:US
Practice Address - Phone:909-790-8603
Practice Address - Fax:909-790-8618
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA49429106H00000X
NMT-CTL0212371106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330489658OtherTAX ID #