Provider Demographics
NPI:1457852725
Name:MCCULLOUGH, NICOLE REALLE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:REALLE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:27440 SW VANDERSCHUERE RD
Mailing Address - Street 2:
Mailing Address - City:HILLSBORO
Mailing Address - State:OR
Mailing Address - Zip Code:97123-9439
Mailing Address - Country:US
Mailing Address - Phone:503-799-4114
Mailing Address - Fax:
Practice Address - Street 1:1411 SW MORRISON ST STE 310
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-1945
Practice Address - Country:US
Practice Address - Phone:503-799-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT1396085718Medicaid