Provider Demographics
NPI:1326131749
Name:MCCULLOUGH, JUNE
Entity Type:Individual
Prefix:DR
First Name:JUNE
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 1:684 COLLEEN DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-5512
Mailing Address - Country:US
Mailing Address - Phone:408-578-7423
Mailing Address - Fax:
Practice Address - Street 1:696 E SANTA CLARA ST STE 110
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95112-1911
Practice Address - Country:US
Practice Address - Phone:408-288-6604
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAU1118237600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237600000XSpeech, Language and Hearing Service ProvidersAudiologist-Hearing Aid Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGAU000660Medicaid
ZZZ13506ZMedicare ID - Type Unspecified