Provider Demographics
NPI:1023668449
Name:CULLINAN, IRELAND SHEA
Entity type:Individual
Prefix:
First Name:IRELAND
Middle Name:SHEA
Last Name:CULLINAN
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 1:499 LOMA ALTA AVE
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95030-6227
Mailing Address - Country:US
Mailing Address - Phone:408-364-4157
Mailing Address - Fax:
Practice Address - Street 1:499 LOMA ALTA AVE
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95030-6227
Practice Address - Country:US
Practice Address - Phone:760-636-9116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-17
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
171M00000X, 106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician