Provider Demographics
NPI:1083764922
Name:MCCULLOCH, ANITA EILEEN (LCSW)
Entity Type:Individual
Prefix:MS
First Name:ANITA
Middle Name:EILEEN
Last Name:MCCULLOCH
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 1:101 W MUHAMMAD ALI BLVD
Mailing Address - Street 2:SUITE 8
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1423
Mailing Address - Country:US
Mailing Address - Phone:502-586-8600
Mailing Address - Fax:
Practice Address - Street 1:2105 CRUMS LN
Practice Address - Street 2:SUITE 8
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40216-4231
Practice Address - Country:US
Practice Address - Phone:502-693-5870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-11
Last Update Date:2016-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY31411041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY30615058Medicaid
KY0453Medicare ID - Type UnspecifiedMEDICARE