Provider Demographics
NPI:1629013602
Name:MCCULLOUGH, AMANDA GAYLE (PT)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GAYLE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 SCHOOLCREST AVE
Mailing Address - Street 2:
Mailing Address - City:CLARE
Mailing Address - State:MI
Mailing Address - Zip Code:48617-1145
Mailing Address - Country:US
Mailing Address - Phone:989-386-9170
Mailing Address - Fax:989-386-9220
Practice Address - Street 1:107 SCHOOLCREST AVE
Practice Address - Street 2:
Practice Address - City:CLARE
Practice Address - State:MI
Practice Address - Zip Code:48617-1145
Practice Address - Country:US
Practice Address - Phone:989-386-9170
Practice Address - Fax:989-386-9220
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5501011835225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP43600008Medicare PIN