Provider Demographics
NPI:1013155217
Name:MCCULLOUGH, LINDA ANN (LMT)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:ANN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:529 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:WV
Mailing Address - Zip Code:26330-1824
Mailing Address - Country:US
Mailing Address - Phone:304-842-4202
Mailing Address - Fax:304-842-6480
Practice Address - Street 1:529 E MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:WV
Practice Address - Zip Code:26330-1824
Practice Address - Country:US
Practice Address - Phone:304-842-4202
Practice Address - Fax:304-842-6480
Is Sole Proprietor?:No
Enumeration Date:2009-01-26
Last Update Date:2009-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV2003-1315174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist