Provider Demographics
NPI:1154817617
Name:MCCULLOUGH, STEPHANIE
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8500 WASHINGTON ST NE STE A1
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87113-1861
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8500 WASHINGTON ST NE STE A1
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87113-1861
Practice Address - Country:US
Practice Address - Phone:505-828-3837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-09
Last Update Date:2018-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician