Provider Demographics
NPI:1235637190
Name:MCCULLOUGH, CANDACE
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:
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 1:1010 E AND WEST RD
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3602
Mailing Address - Country:US
Mailing Address - Phone:726-677-7081
Mailing Address - Fax:716-677-7073
Practice Address - Street 1:1010 E AND WEST RD
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3602
Practice Address - Country:US
Practice Address - Phone:716-677-7081
Practice Address - Fax:716-677-7073
Is Sole Proprietor?:No
Enumeration Date:2018-01-25
Last Update Date:2018-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health