Provider Demographics
NPI:1699039933
Name:MCCULLOUGH, MARY IRENE (LSSP, LPC-S, NCC)
Entity Type:Individual
Prefix:DR
First Name:MARY
Middle Name:IRENE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LSSP, LPC-S, NCC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11757 KATY FWY STE 1300
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77079-1725
Mailing Address - Country:US
Mailing Address - Phone:832-429-4917
Mailing Address - Fax:
Practice Address - Street 1:11757 KATY FWY STE 1300
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77079-1725
Practice Address - Country:US
Practice Address - Phone:832-429-4917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-02
Last Update Date:2016-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX64887101Y00000X, 101YP2500X, 101YS0200X, 101YM0800X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchool
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX300235402Medicaid