Provider Demographics
NPI:1477678076
Name:MCCULLOCH, NYLA
Entity Type:Individual
Prefix:
First Name:NYLA
Middle Name:
Last Name:MCCULLOCH
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 1:1 W WATER ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:WAKEFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01880-2907
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 W WATER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:WAKEFIELD
Practice Address - State:MA
Practice Address - Zip Code:01880-2907
Practice Address - Country:US
Practice Address - Phone:781-245-8185
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1059341041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAP04787OtherBLUE CROSS BLUE SHIELD
MAMCP04787Medicare ID - Type UnspecifiedMEDICARE NUMBER