Provider Demographics
NPI:1982588323
Name:CATES CULLISON, MARY KATHLEEN (LCAC)
Entity type:Individual
Prefix:
First Name:MARY KATHLEEN
Middle Name:
Last Name:CATES CULLISON
Suffix:
Gender:F
Credentials:LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:417 ARNOLD CT
Mailing Address - Street 2:
Mailing Address - City:KOKOMO
Mailing Address - State:IN
Mailing Address - Zip Code:46902-3702
Mailing Address - Country:US
Mailing Address - Phone:765-450-4843
Mailing Address - Fax:765-450-4895
Practice Address - Street 1:417 ARNOLD CT
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-3702
Practice Address - Country:US
Practice Address - Phone:765-450-4843
Practice Address - Fax:765-450-4895
Is Sole Proprietor?:Yes
Enumeration Date:2025-07-31
Last Update Date:2025-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87001439A101YA0400X
IN34005813A1041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN34005813AOtherLICENSED CLINICAL SOCIAL WORKER LICENSE