Provider Demographics
NPI:1407468119
Name:MCCULLOUGH SPEECH THERAPY, PLLC
Entity Type:Organization
Organization Name:MCCULLOUGH SPEECH THERAPY, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VANESSA
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:585-764-1430
Mailing Address - Street 1:615 GREENWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27514-5921
Mailing Address - Country:US
Mailing Address - Phone:585-764-1430
Mailing Address - Fax:
Practice Address - Street 1:615 GREENWOOD RD
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27514-5921
Practice Address - Country:US
Practice Address - Phone:585-764-1430
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-24
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0700XAmbulatory Health Care FacilitiesClinic/CenterHearing and Speech
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1023375078Medicaid