Provider Demographics
NPI:1659588408
Name:MCCULLOUGH, CANDACE A (PHD, LCPC, ACS, DCC)
Entity Type:Individual
Prefix:DR
First Name:CANDACE
Middle Name:A
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PHD, LCPC, ACS, DCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 WHISPERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:N BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20852-3668
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:301-493-6044
Practice Address - Street 1:11110 WHISPERWOOD LN
Practice Address - Street 2:
Practice Address - City:N BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20852-3668
Practice Address - Country:US
Practice Address - Phone:301-493-6044
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-17
Last Update Date:2011-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLC 0662101YM0800X
DCPRC13760101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD4093585 00Medicaid
MDJ4880001OtherBC BS