Provider Demographics
NPI:1861819211
Name:MCCULLOUGH, ALYSSA
Entity Type:Individual
Prefix:
First Name:ALYSSA
Middle Name:
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 1:106 SANDY BRAE DR
Mailing Address - Street 2:
Mailing Address - City:CANONSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:15317-4956
Mailing Address - Country:US
Mailing Address - Phone:412-913-6792
Mailing Address - Fax:
Practice Address - Street 1:3600 SAW MILL RUN BLVD
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:PA
Practice Address - Zip Code:15227-2710
Practice Address - Country:US
Practice Address - Phone:412-882-4140
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-24
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT023497225100000X
IL070020528225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist