Provider Demographics
NPI:1760938427
Name:MCCULLOUGH, JANICE KAY (LMFT)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:KAY
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:KAY
Other - Last Name:DOLENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 1434
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94023-1434
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1000 FREMONT AVE
Practice Address - Street 2:SUITE 152
Practice Address - City:LOS ALTOS
Practice Address - State:CA
Practice Address - Zip Code:94024-6093
Practice Address - Country:US
Practice Address - Phone:650-397-1032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA93687106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist