Provider Demographics
NPI:1225213978
Name:MCCULLOUGH, BRIDGETTE DIANN
Entity Type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:DIANN
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 1:5607 CALAIS DR
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75704-2035
Mailing Address - Country:US
Mailing Address - Phone:903-363-9682
Mailing Address - Fax:903-363-9682
Practice Address - Street 1:3035 ORR DR
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-1038
Practice Address - Country:US
Practice Address - Phone:903-592-4857
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-31
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator