Provider Demographics
NPI:1053089326
Name:MCCULLEY, HEATHER
Entity Type:Individual
Prefix:
First Name:HEATHER
Middle Name:
Last Name:MCCULLEY
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 1:9700 TARA DR
Mailing Address - Street 2:
Mailing Address - City:DUNKIRK
Mailing Address - State:MD
Mailing Address - Zip Code:20754-3004
Mailing Address - Country:US
Mailing Address - Phone:130-178-7746
Mailing Address - Fax:
Practice Address - Street 1:4500 FORBES BLVD STE 200
Practice Address - Street 2:
Practice Address - City:GLENARDEN
Practice Address - State:MD
Practice Address - Zip Code:20706-6316
Practice Address - Country:US
Practice Address - Phone:301-787-7466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-09-01
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD106S00000X106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician