Provider Demographics
NPI:1275790438
Name:THE MCCULLOUGH CENTER FOR MENTAL HEALTH SERVICES INC
Entity Type:Organization
Organization Name:THE MCCULLOUGH CENTER FOR MENTAL HEALTH SERVICES INC
Other - Org Name:MCCULLOUGH CENTER FOR MENTAL HEALTH SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CEASAR
Authorized Official - Middle Name:
Authorized Official - Last Name:GARZA
Authorized Official - Suffix:
Authorized Official - Credentials:LPC
Authorized Official - Phone:210-736-1762
Mailing Address - Street 1:2515 MCCULLOUGH AVE STE 101
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78212-3585
Mailing Address - Country:US
Mailing Address - Phone:210-736-1762
Mailing Address - Fax:210-736-3156
Practice Address - Street 1:2515 MCCULLOUGH AVE STE 101
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78212-3585
Practice Address - Country:US
Practice Address - Phone:210-736-1762
Practice Address - Fax:210-736-3156
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-16
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X, 101YM0800X, 101YP2500X, 1041C0700X, 106H00000X, 133N00000X, 163WP0808X, 207Q00000X
TX19585101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
No101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessionalGroup - Multi-Specialty
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Multi-Specialty
No133N00000XDietary & Nutritional Service ProvidersNutritionistGroup - Multi-Specialty
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX405258101Medicaid
TX405440501Medicaid
TX1548206774OtherNPI
TX1669019170OtherNPI
TX174358502Medicaid
TX1417595489OtherNPI
TX1477521904OtherNPI
TX1770087280OtherNPI
TX198721601Medicaid