Provider Demographics
NPI:1114092590
Name:MCCULLOCH, VICTORIA ANN (LCSW)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:ANN
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 1:117 W BUNNY AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93458-2805
Mailing Address - Country:US
Mailing Address - Phone:805-739-3474
Mailing Address - Fax:805-739-3982
Practice Address - Street 1:316 S STRATFORD AVE
Practice Address - Street 2:SUITE B
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93454-5908
Practice Address - Country:US
Practice Address - Phone:805-332-8446
Practice Address - Fax:805-332-8173
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2016-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CALCS 16790104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes104100000XBehavioral Health & Social Service ProvidersSocial Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAFHC03884FMedicaid
CALCS 16790OtherBBSE
CAFHC70593FMedicaid
CAFHC03884FMedicaid
CA551903Medicare Oscar/Certification
W1508Medicare PIN
CAW1508AMedicare PIN