Provider Demographics
NPI:1528365954
Name:MCCULLY, PAMELA JEAN (PTA)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:JEAN
Last Name:MCCULLY
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:904 YUKON DR
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-6345
Mailing Address - Country:US
Mailing Address - Phone:814-521-4946
Mailing Address - Fax:
Practice Address - Street 1:904 YUKON DR
Practice Address - Street 2:
Practice Address - City:MANSFIELD
Practice Address - State:TX
Practice Address - Zip Code:76063-6345
Practice Address - Country:US
Practice Address - Phone:814-521-4946
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-21
Last Update Date:2011-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2011904171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor