Provider Demographics
NPI:1851994727
Name:MCCULLOUGH, ANNETTE MARIE
Entity Type:Individual
Prefix:
First Name:ANNETTE
Middle Name:MARIE
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 1:1133 SAN LEANDRO BLVD
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-1536
Mailing Address - Country:US
Mailing Address - Phone:510-957-6444
Mailing Address - Fax:
Practice Address - Street 1:1133 SAN LEANDRO BLVD
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-1536
Practice Address - Country:US
Practice Address - Phone:510-957-6444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator