Provider Demographics
NPI:1922216837
Name:MCCULLOUGH, MARY (MA LMHC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MA LMHC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11415 NE 128TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:KIRKLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98034-6314
Mailing Address - Country:US
Mailing Address - Phone:206-570-6372
Mailing Address - Fax:
Practice Address - Street 1:11415 NE 128TH ST STE 100
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-6314
Practice Address - Country:US
Practice Address - Phone:206-570-6372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health