Provider Demographics
NPI:1952855157
Name:MCCULLOUGH, SAMANTHA (LMSW, CAADC)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LMSW, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1108 LAPEER RD
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-2704
Mailing Address - Country:US
Mailing Address - Phone:810-232-7919
Mailing Address - Fax:
Practice Address - Street 1:6295 N ELMS RD
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:MI
Practice Address - Zip Code:48433-9002
Practice Address - Country:US
Practice Address - Phone:810-243-2660
Practice Address - Fax:810-309-8833
Is Sole Proprietor?:No
Enumeration Date:2016-08-05
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YA0400X
MI68011065971041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)