Provider Demographics
NPI:1043270895
Name:MCCULLOUGH, SANDRA FAYE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:SANDRA
Middle Name:FAYE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7516 ENTERPRISE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138
Mailing Address - Country:US
Mailing Address - Phone:901-755-5802
Mailing Address - Fax:901-757-2249
Practice Address - Street 1:7516 ENTERPRISE
Practice Address - Street 2:SUITE 1
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138
Practice Address - Country:US
Practice Address - Phone:901-755-5802
Practice Address - Fax:901-757-2249
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNLSW4120104100000X
AR1722C104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
3925698Medicare ID - Type Unspecified