Provider Demographics
NPI:1205225323
Name:MCCULLOCH, DEVAN
Entity Type:Individual
Prefix:
First Name:DEVAN
Middle Name:
Last Name:MCCULLOCH
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 1:10713 E LINDENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHANA
Mailing Address - State:IL
Mailing Address - Zip Code:61015-9673
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:201 LINCOLN STATUE DR
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021-2000
Practice Address - Country:US
Practice Address - Phone:815-284-1700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-13
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070070147225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400324572Medicare PIN
ILF400324588Medicare PIN
ILF400324579Medicare PIN