Provider Demographics
NPI:1699000455
Name:MCCULLOUGH, ELLEN NEWELL (PT, DPT)
Entity Type:Individual
Prefix:MS
First Name:ELLEN
Middle Name:NEWELL
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 HIGH MEADOW TRAIL
Mailing Address - Street 2:
Mailing Address - City:SOUTH LAKE TAHOE
Mailing Address - State:CA
Mailing Address - Zip Code:96150
Mailing Address - Country:US
Mailing Address - Phone:408-313-0899
Mailing Address - Fax:408-354-2228
Practice Address - Street 1:1900 HIGH MEADOW TRAIL
Practice Address - Street 2:
Practice Address - City:SOUTH LAKE TAHOE
Practice Address - State:CA
Practice Address - Zip Code:96150
Practice Address - Country:US
Practice Address - Phone:408-313-0899
Practice Address - Fax:408-354-2228
Is Sole Proprietor?:No
Enumeration Date:2009-10-13
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA36087225100000X
CAPT36087225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist