Provider Demographics
NPI:1629759154
Name:MCCULLUM, MARIO
Entity Type:Individual
Prefix:
First Name:MARIO
Middle Name:
Last Name:MCCULLUM
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 1:5855 STREAMVIEW DR
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-3910
Mailing Address - Country:US
Mailing Address - Phone:619-287-5460
Mailing Address - Fax:
Practice Address - Street 1:5855 STREAMVIEW DR
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92105-3910
Practice Address - Country:US
Practice Address - Phone:619-287-5460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-27
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)