Provider Demographics
NPI:1760973242
Name:MCCULLOCH, ANNA VICTORIA
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:VICTORIA
Last Name:MCCULLOCH
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 1:2268 TRIPLETT RD
Mailing Address - Street 2:
Mailing Address - City:ACKERMAN
Mailing Address - State:MS
Mailing Address - Zip Code:39735-6669
Mailing Address - Country:US
Mailing Address - Phone:662-285-8136
Mailing Address - Fax:
Practice Address - Street 1:1001 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2125
Practice Address - Country:US
Practice Address - Phone:662-323-6360
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS4395235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist