Provider Demographics
NPI:1578067542
Name:BRANDY NICOLE MCCULLOUCH
Entity Type:Organization
Organization Name:BRANDY NICOLE MCCULLOUCH
Other - Org Name:A-WELLNESS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRANDY
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOUCH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-934-1526
Mailing Address - Street 1:708 COWBOY CROSS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6746
Mailing Address - Country:US
Mailing Address - Phone:702-934-1526
Mailing Address - Fax:
Practice Address - Street 1:708 COWBOY CROSS AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89081
Practice Address - Country:US
Practice Address - Phone:702-934-1526
Practice Address - Fax:702-934-1526
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-22
Last Update Date:2018-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health