Provider Demographics
NPI:1902178080
Name:MCCULLOUGH, KENNETH (LADC, LCPC)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:LADC, LCPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 WATER ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:HALLOWELL
Mailing Address - State:ME
Mailing Address - Zip Code:04347
Mailing Address - Country:US
Mailing Address - Phone:207-430-3777
Mailing Address - Fax:207-621-4020
Practice Address - Street 1:52 WATER ST
Practice Address - Street 2:SUITE 2
Practice Address - City:HALLOWELL
Practice Address - State:ME
Practice Address - Zip Code:04347
Practice Address - Country:US
Practice Address - Phone:207-430-3777
Practice Address - Fax:207-621-4020
Is Sole Proprietor?:No
Enumeration Date:2012-02-03
Last Update Date:2015-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MELC197101YA0400X
MECC1102101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)