Provider Demographics
NPI:1740768829
Name:MCCULLOUGH, JANICE KAYE
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:KAYE
Last Name:MCCULLOUGH
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 1:1699 WOOD PL
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75601-4047
Mailing Address - Country:US
Mailing Address - Phone:903-918-5532
Mailing Address - Fax:
Practice Address - Street 1:406 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINNSBORO
Practice Address - State:TX
Practice Address - Zip Code:75494-3226
Practice Address - Country:US
Practice Address - Phone:903-342-6790
Practice Address - Fax:903-342-6796
Is Sole Proprietor?:No
Enumeration Date:2018-08-01
Last Update Date:2018-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX105273225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX105273OtherOCCUPATIONAL LICENSE