Provider Demographics
NPI:1689122418
Name:MCCULLOCH, CAITLIN
Entity Type:Individual
Prefix:
First Name:CAITLIN
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 E REDLANDS BLVD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-4775
Mailing Address - Country:US
Mailing Address - Phone:909-735-7654
Mailing Address - Fax:909-796-2122
Practice Address - Street 1:10421 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-2838
Practice Address - Country:US
Practice Address - Phone:951-217-4007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-09-21
Last Update Date:2016-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21945235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist