Provider Demographics
NPI:1427183045
Name:MCCULLOUGH, HENRY KENNETH (COUNSELOR)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:KENNETH
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:COUNSELOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:442 E NEW YORK AVE
Mailing Address - Street 2:SUITE 10
Mailing Address - City:DELAND
Mailing Address - State:FL
Mailing Address - Zip Code:32724-5553
Mailing Address - Country:US
Mailing Address - Phone:386-738-1085
Mailing Address - Fax:386-738-1085
Practice Address - Street 1:442 E NEW YORK AVE
Practice Address - Street 2:SUITE 10
Practice Address - City:DELAND
Practice Address - State:FL
Practice Address - Zip Code:32724-5553
Practice Address - Country:US
Practice Address - Phone:386-738-1085
Practice Address - Fax:386-738-1085
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMH 2762101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health