Provider Demographics
NPI:1437373826
Name:MCCULLOUGH, CAROLYN RAYE (COTA)
Entity Type:Individual
Prefix:MS
First Name:CAROLYN
Middle Name:RAYE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:COTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:707 WILDABON AVE
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-3457
Mailing Address - Country:US
Mailing Address - Phone:863-678-9791
Mailing Address - Fax:
Practice Address - Street 1:409 S 10TH ST
Practice Address - Street 2:
Practice Address - City:HAINES CITY
Practice Address - State:FL
Practice Address - Zip Code:33844-5603
Practice Address - Country:US
Practice Address - Phone:863-422-8656
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOTA7259224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant