Provider Demographics
NPI:1316538648
Name:MCCULLOCH, EMALEY B (MED BCBA)
Entity Type:Individual
Prefix:
First Name:EMALEY
Middle Name:B
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:MED BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 TYRONE ST
Mailing Address - Street 2:
Mailing Address - City:EL CAJON
Mailing Address - State:CA
Mailing Address - Zip Code:92020-2234
Mailing Address - Country:US
Mailing Address - Phone:808-349-0645
Mailing Address - Fax:
Practice Address - Street 1:601 TYRONE ST
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92020-2234
Practice Address - Country:US
Practice Address - Phone:808-349-0645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-29
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1-12-12064103K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst