Provider Demographics
NPI:1083994701
Name:MCCULLOUGH, WANDA GRACE (LCSW)
Entity Type:Individual
Prefix:MS
First Name:WANDA
Middle Name:GRACE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:MS
Other - First Name:WANDA
Other - Middle Name:GRACE
Other - Last Name:SHARP
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LCSW
Mailing Address - Street 1:214 GRACE LN
Mailing Address - Street 2:
Mailing Address - City:FLORA
Mailing Address - State:MS
Mailing Address - Zip Code:39071-6005
Mailing Address - Country:US
Mailing Address - Phone:601-500-2727
Mailing Address - Fax:
Practice Address - Street 1:332 HIGHWAY 12 W
Practice Address - Street 2:
Practice Address - City:KOSCIUSKO
Practice Address - State:MS
Practice Address - Zip Code:39090-3209
Practice Address - Country:US
Practice Address - Phone:662-289-1800
Practice Address - Fax:662-289-9770
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-25
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSC11971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical