Provider Demographics
NPI:1194014670
Name:MCCULLOUGH, DEAN RYAN (MSW LCSW)
Entity Type:Individual
Prefix:
First Name:DEAN
Middle Name:RYAN
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MSW LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1003 MARTIN LUTHER KING DR
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701-1429
Mailing Address - Country:US
Mailing Address - Phone:309-827-6026
Mailing Address - Fax:
Practice Address - Street 1:1003 MARTIN LUTHER KING DR
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701-1429
Practice Address - Country:US
Practice Address - Phone:309-827-6026
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-05
Last Update Date:2019-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1490146491041C0700X
IL149.0146491041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical