Provider Demographics
NPI:1235387093
Name:MCCULLOUGH, TEDDI LEE
Entity Type:Individual
Prefix:MS
First Name:TEDDI
Middle Name:LEE
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 1:833 LITCHFIELD ST
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67203-3106
Mailing Address - Country:US
Mailing Address - Phone:316-269-4539
Mailing Address - Fax:
Practice Address - Street 1:833 LITCHFIELD ST
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67203-3106
Practice Address - Country:US
Practice Address - Phone:316-269-4539
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-05
Last Update Date:2008-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS26-3288910OtherEMPLOYER INDENTIFICATION NUMBER-IRS