Provider Demographics
NPI:1164735346
Name:MCCULLUM-JOHNSON, TYHILYA KUNISHA (LCPC)
Entity Type:Individual
Prefix:
First Name:TYHILYA
Middle Name:KUNISHA
Last Name:MCCULLUM-JOHNSON
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9721 165TH ST STE 21
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-4511
Mailing Address - Country:US
Mailing Address - Phone:708-671-8946
Mailing Address - Fax:
Practice Address - Street 1:2844 GRAND BLVD
Practice Address - Street 2:
Practice Address - City:HIGHLAND
Practice Address - State:IN
Practice Address - Zip Code:46322-1238
Practice Address - Country:US
Practice Address - Phone:309-634-6118
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-16
Last Update Date:2023-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL178006611101Y00000X, 101YM0800X
IL180-007578101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL37-0934175OtherBRIDGEWAY FEIN