Provider Demographics
NPI:1083897912
Name:MCCULLOCH, PHOENIX (MSW)
Entity Type:Individual
Prefix:
First Name:PHOENIX
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 NE IRVING ST
Mailing Address - Street 2:SUITE 250
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-2243
Mailing Address - Country:US
Mailing Address - Phone:503-233-4356
Mailing Address - Fax:
Practice Address - Street 1:3050 SE DIVISION ST STE 205
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-1997
Practice Address - Country:US
Practice Address - Phone:971-808-2115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-13
Last Update Date:2023-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker