Provider Demographics
NPI:1922485739
Name:MCCULLOUGH, CLARE MARIE (LPC)
Entity Type:Individual
Prefix:
First Name:CLARE
Middle Name:MARIE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 EDGEWORTHE DR SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-7809
Mailing Address - Country:US
Mailing Address - Phone:989-429-2734
Mailing Address - Fax:
Practice Address - Street 1:477 EDGEWORTHE DR SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-7809
Practice Address - Country:US
Practice Address - Phone:989-429-2734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-30
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6401011510101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional