Provider Demographics
NPI:1134191729
Name:MCCULLOUGH, SHIRLEY WALLEY (MSW)
Entity type:Individual
Prefix:MRS
First Name:SHIRLEY
Middle Name:WALLEY
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 886912
Mailing Address - Street 2:
Mailing Address - City:GREAT LAKES
Mailing Address - State:IL
Mailing Address - Zip Code:60088-6912
Mailing Address - Country:US
Mailing Address - Phone:847-726-6021
Mailing Address - Fax:
Practice Address - Street 1:3001 6TH ST
Practice Address - Street 2:
Practice Address - City:GREAT LAKES
Practice Address - State:IL
Practice Address - Zip Code:60088-2833
Practice Address - Country:US
Practice Address - Phone:847-688-6755
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACSW1000101041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical