Provider Demographics
NPI:1093153181
Name:MCCULLOUGH, WILLIE JAMES
Entity Type:Individual
Prefix:
First Name:WILLIE
Middle Name:JAMES
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 N CLASSEN BLVD
Mailing Address - Street 2:STE 110
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73106-6015
Mailing Address - Country:US
Mailing Address - Phone:405-606-4441
Mailing Address - Fax:
Practice Address - Street 1:1901 N CLASSEN BLVD
Practice Address - Street 2:STE 110
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73106-6015
Practice Address - Country:US
Practice Address - Phone:405-606-4441
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-11
Last Update Date:2013-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst