Provider Demographics
NPI:1013293554
Name:DEE-MCCULLOUGH, CONSTANCE DEBORAH (MS, CCC-SP)
Entity Type:Individual
Prefix:MS
First Name:CONSTANCE
Middle Name:DEBORAH
Last Name:DEE-MCCULLOUGH
Suffix:
Gender:F
Credentials:MS, CCC-SP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:136 SALEM DR
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-1912
Mailing Address - Country:US
Mailing Address - Phone:607-257-1530
Mailing Address - Fax:
Practice Address - Street 1:136 SALEM DR
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-1912
Practice Address - Country:US
Practice Address - Phone:607-257-1530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-10-28
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006536-1235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist