Provider Demographics
NPI:1699201715
Name:MCCULLOUGH, LEISA ANNETTE (CCC-SLP)
Entity Type:Individual
Prefix:
First Name:LEISA
Middle Name:ANNETTE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:144 HUBER ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-6983
Mailing Address - Country:US
Mailing Address - Phone:662-397-8964
Mailing Address - Fax:
Practice Address - Street 1:2500 N STATE ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4500
Practice Address - Country:US
Practice Address - Phone:662-397-8964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-10
Last Update Date:2017-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS3909235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist