Provider Demographics
NPI:1609050871
Name:MCCULLOCH, KEITH CHARLES
Entity Type:Individual
Prefix:MR
First Name:KEITH
Middle Name:CHARLES
Last Name:MCCULLOCH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 0BERLIN
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91205
Mailing Address - Country:US
Mailing Address - Phone:818-484-1591
Mailing Address - Fax:
Practice Address - Street 1:13741 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:SYLMAR
Practice Address - State:CA
Practice Address - Zip Code:91342-3133
Practice Address - Country:US
Practice Address - Phone:818-833-9789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-24
Last Update Date:2007-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)