Provider Demographics
NPI:1346535119
Name:MCCULLOUGH, PATRICK JAMES (LCSW)
Entity Type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:JAMES
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11395 NW MCCOIN RD
Mailing Address - Street 2:
Mailing Address - City:PRINEVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97754-8287
Mailing Address - Country:US
Mailing Address - Phone:541-410-0430
Mailing Address - Fax:
Practice Address - Street 1:11395 NW MCCOIN RD
Practice Address - Street 2:
Practice Address - City:PRINEVILLE
Practice Address - State:OR
Practice Address - Zip Code:97754-8287
Practice Address - Country:US
Practice Address - Phone:541-410-0430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-09
Last Update Date:2011-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR46061041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical