Provider Demographics
NPI:1326339060
Name:MCCULLOUGH, CYNTHIA LYNN (MA, BCBA)
Entity Type:Individual
Prefix:MRS
First Name:CYNTHIA
Middle Name:LYNN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MA, BCBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 QUIET STAR CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95747-7123
Mailing Address - Country:US
Mailing Address - Phone:408-596-0607
Mailing Address - Fax:
Practice Address - Street 1:730 SUNRISE AVE
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:CA
Practice Address - Zip Code:95661-4567
Practice Address - Country:US
Practice Address - Phone:408-596-0607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-28
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA900703609OtherEIN