Provider Demographics
NPI:1013585314
Name:MCCULLY, RACHELLE ELAINE
Entity Type:Individual
Prefix:
First Name:RACHELLE
Middle Name:ELAINE
Last Name:MCCULLY
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 1:25117 SW PARKWAY AVE STE D
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-9697
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10 MOUNTAIN VIEW DR
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MT
Practice Address - Zip Code:59917-9439
Practice Address - Country:US
Practice Address - Phone:406-297-2541
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-14
Last Update Date:2021-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
235Z00000X
MTSLP-SP-LIC-9767235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty