Provider Demographics
NPI:1679073092
Name:MCCULLOUGH, BLAKE (LMSW)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2900 HANNAH BLVD STE 104
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-5380
Mailing Address - Country:US
Mailing Address - Phone:517-253-6320
Mailing Address - Fax:
Practice Address - Street 1:2900 HANNAH BLVD STE 104
Practice Address - Street 2:
Practice Address - City:EAST LANSING
Practice Address - State:MI
Practice Address - Zip Code:48823-5380
Practice Address - Country:US
Practice Address - Phone:517-253-6320
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-13
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011040121041C0700X
MI6801100146104100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No104100000XBehavioral Health & Social Service ProvidersSocial Worker