Provider Demographics
NPI:1326164732
Name:MCCULLOUGH ROMERO, JUDITH (PHD)
Entity Type:Individual
Prefix:DR
First Name:JUDITH
Middle Name:
Last Name:MCCULLOUGH ROMERO
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:DR
Other - First Name:JUDITH
Other - Middle Name:
Other - Last Name:MCCULLOUGH
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PHD
Mailing Address - Street 1:101 TREMONT ST FL 6
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02108-5004
Mailing Address - Country:US
Mailing Address - Phone:786-683-1234
Mailing Address - Fax:
Practice Address - Street 1:280 COBB PKWY S STE 60
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30060-6531
Practice Address - Country:US
Practice Address - Phone:678-820-7373
Practice Address - Fax:844-947-4322
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2024-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPSY003071103TC2200X, 103TC0700X
FLPY6962103TC2200X, 103TC0700X
RIPS02248103TC0700X, 103TC2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinical
No103TC2200XBehavioral Health & Social Service ProvidersPsychologistClinical Child & Adolescent