Provider Demographics
NPI:1003572843
Name:MCCULLOUGH, SHERESE TWYANA
Entity Type:Individual
Prefix:
First Name:SHERESE
Middle Name:TWYANA
Last Name:MCCULLOUGH
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 1:2419 OLD THOMPSON BRIDGE RD APT J5
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-1167
Mailing Address - Country:US
Mailing Address - Phone:678-858-3322
Mailing Address - Fax:
Practice Address - Street 1:2419 OLD THOMPSON BRIDGE RD APT J5
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-1167
Practice Address - Country:US
Practice Address - Phone:678-858-3322
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-16
Last Update Date:2021-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YP1600XBehavioral Health & Social Service ProvidersCounselorPastoral
No106E00000XBehavioral Health & Social Service ProvidersAssistant Behavior Analyst