Provider Demographics
NPI:1386006922
Name:MCCULLOUGH, ROBERT E II
Entity Type:Individual
Prefix:MR
First Name:ROBERT
Middle Name:E
Last Name:MCCULLOUGH
Suffix:II
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 CONTINENTAL PL
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:WA
Mailing Address - Zip Code:98273-5633
Mailing Address - Country:US
Mailing Address - Phone:360-755-6400
Mailing Address - Fax:360-755-6407
Practice Address - Street 1:1905 CONTINENTAL PL
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:WA
Practice Address - Zip Code:98273-5633
Practice Address - Country:US
Practice Address - Phone:360-755-6400
Practice Address - Fax:360-755-6407
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-23
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA00004280101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)