Provider Demographics
NPI:1093982506
Name:MCCULLOUGH, RODNEY R (MA)
Entity Type:Individual
Prefix:
First Name:RODNEY
Middle Name:R
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 271
Mailing Address - Street 2:
Mailing Address - City:WORTHINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:26591-0271
Mailing Address - Country:US
Mailing Address - Phone:304-657-1656
Mailing Address - Fax:
Practice Address - Street 1:170 THOMPSON DR
Practice Address - Street 2:SUITE 103
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-2608
Practice Address - Country:US
Practice Address - Phone:304-842-6609
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-14
Last Update Date:2010-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV774103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810012357Medicaid