Provider Demographics
NPI:1942239934
Name:MCCULLOCH, MARLA SUZANNE (MSS, LCSW, CEAP)
Entity Type:Individual
Prefix:MS
First Name:MARLA
Middle Name:SUZANNE
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:MSS, LCSW, CEAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:538 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3919
Mailing Address - Country:US
Mailing Address - Phone:610-716-1136
Mailing Address - Fax:
Practice Address - Street 1:114 CROCKETT RD
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-3014
Practice Address - Country:US
Practice Address - Phone:610-716-1136
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PACW-0148881041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA09828NKTMedicare ID - Type UnspecifiedCLINICAL SOCIAL WORKER