Provider Demographics
NPI:1457477838
Name:MCCULLOUGH, THERESA (PT)
Entity Type:Individual
Prefix:MS
First Name:THERESA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1725 VERONA DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-3545
Mailing Address - Country:US
Mailing Address - Phone:434-466-3317
Mailing Address - Fax:434-979-8536
Practice Address - Street 1:1102 ROSE HILL DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22903-5128
Practice Address - Country:US
Practice Address - Phone:434-979-8628
Practice Address - Fax:434-979-8536
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA23052034542251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA209238OtherSOUTHERN HEALTH
VA7493361OtherAETNA