Provider Demographics
NPI:1225515489
Name:MCCULLEY, KAITLIN CHELSEA
Entity Type:Individual
Prefix:
First Name:KAITLIN
Middle Name:CHELSEA
Last Name:MCCULLEY
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 1:6417 ODANA RD STE 25
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WI
Mailing Address - Zip Code:53719-1159
Mailing Address - Country:US
Mailing Address - Phone:608-640-3646
Mailing Address - Fax:
Practice Address - Street 1:6417 ODANA RD STE 25
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53719-1159
Practice Address - Country:US
Practice Address - Phone:608-640-3646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-20
Last Update Date:2018-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI10217-146225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist