Provider Demographics
NPI:1760993067
Name:MCCULLOUGH, CASSIDY RENEE (OTR/L)
Entity Type:Individual
Prefix:
First Name:CASSIDY
Middle Name:RENEE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:CASSIDY
Other - Middle Name:RENEE
Other - Last Name:SULLIVAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:412 N BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SHAWNEE
Mailing Address - State:OK
Mailing Address - Zip Code:74801-6922
Mailing Address - Country:US
Mailing Address - Phone:405-273-1523
Mailing Address - Fax:405-273-1743
Practice Address - Street 1:412 N BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:OK
Practice Address - Zip Code:74801-6922
Practice Address - Country:US
Practice Address - Phone:405-273-1523
Practice Address - Fax:405-273-1743
Is Sole Proprietor?:No
Enumeration Date:2017-10-13
Last Update Date:2017-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2128225XP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225XP0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistPediatrics