Provider Demographics
NPI:1447760285
Name:MCCULLOUGH, ADIA (LMT)
Entity Type:Individual
Prefix:
First Name:ADIA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2715 COVENTRY CT
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5431
Mailing Address - Country:US
Mailing Address - Phone:810-875-3234
Mailing Address - Fax:
Practice Address - Street 1:35560 GRAND RIVER AVE STE 225
Practice Address - Street 2:
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48335-3123
Practice Address - Country:US
Practice Address - Phone:734-276-3424
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-06
Last Update Date:2017-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501007262225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist