Provider Demographics
NPI:1902398803
Name:MCCULLOCH, ASHLEY (COTA/L, DOR)
Entity Type:Individual
Prefix:MISS
First Name:ASHLEY
Middle Name:
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:COTA/L, DOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:WA
Mailing Address - Zip Code:98632-2601
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:917 7TH AVE
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:WA
Practice Address - Zip Code:98632-2601
Practice Address - Country:US
Practice Address - Phone:360-425-5910
Practice Address - Fax:360-425-0318
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA60216733224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant