Provider Demographics
NPI:1578014098
Name:MCCULLOUGH, KATHRYN ELLEN (LCSW)
Entity Type:Individual
Prefix:MRS
First Name:KATHRYN
Middle Name:ELLEN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:120 ROTH RD
Mailing Address - Street 2:
Mailing Address - City:DAYVILLE
Mailing Address - State:CT
Mailing Address - Zip Code:06241-1416
Mailing Address - Country:US
Mailing Address - Phone:401-456-2000
Mailing Address - Fax:401-456-6744
Practice Address - Street 1:825 CHALKSTONE AVE
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02908-4728
Practice Address - Country:US
Practice Address - Phone:401-456-2000
Practice Address - Fax:401-456-6744
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-19
Last Update Date:2016-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RICSW1628101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)