Provider Demographics
NPI:1457656357
Name:MCCULLOCH, LYNNE M (OTR,MAC,LCAC)
Entity Type:Individual
Prefix:MS
First Name:LYNNE
Middle Name:M
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:OTR,MAC,LCAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1138 S HIGH SCHOOL RD
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46241-3122
Mailing Address - Country:US
Mailing Address - Phone:317-241-9644
Mailing Address - Fax:317-241-9730
Practice Address - Street 1:6531 W WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46241-3026
Practice Address - Country:US
Practice Address - Phone:317-241-9644
Practice Address - Fax:317-241-9730
Is Sole Proprietor?:Yes
Enumeration Date:2011-01-24
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN87000236A101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)