Provider Demographics
NPI:1346653151
Name:MCCULLOUGH, MARY (LAC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4508 ATLANTIC AVE STE A505
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90807-1520
Mailing Address - Country:US
Mailing Address - Phone:310-435-1248
Mailing Address - Fax:
Practice Address - Street 1:4508 ATLANTIC AVE STE A505
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90807-1520
Practice Address - Country:US
Practice Address - Phone:310-435-1248
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-09
Last Update Date:2020-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA13078171100000X
CAPTGL604246Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No246Z00000XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Other