Provider Demographics
NPI:1497970206
Name:MCCULLOUGH, ANNETTE VICTORIA (OTR)
Entity Type:Individual
Prefix:MRS
First Name:ANNETTE
Middle Name:VICTORIA
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 SHELDON TER
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07106-3315
Mailing Address - Country:US
Mailing Address - Phone:973-972-5102
Mailing Address - Fax:973-972-5725
Practice Address - Street 1:150 BERGEN ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07103-2496
Practice Address - Country:US
Practice Address - Phone:973-972-5102
Practice Address - Fax:973-972-5725
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJTR 00750225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ310119Medicare ID - Type Unspecified