Provider Demographics
NPI:1831669134
Name:MCCULLOUGH, DION MARIE (MA, LLMFT)
Entity Type:Individual
Prefix:
First Name:DION
Middle Name:MARIE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MA, LLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11774 FARLEY
Mailing Address - Street 2:
Mailing Address - City:REDFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48239-2454
Mailing Address - Country:US
Mailing Address - Phone:313-485-4510
Mailing Address - Fax:
Practice Address - Street 1:9329 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:REDFORD
Practice Address - State:MI
Practice Address - Zip Code:48239-1260
Practice Address - Country:US
Practice Address - Phone:313-937-9500
Practice Address - Fax:313-957-9504
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-29
Last Update Date:2022-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4101006779251B00000X
MI4151000365106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
No106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1467937870Medicaid