Provider Demographics
NPI:1205440112
Name:MCCULLOUGH, VANESSA RENEE SMITH
Entity type:Individual
Prefix:MRS
First Name:VANESSA
Middle Name:RENEE SMITH
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12645 TEACUP WAY
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46235-6115
Mailing Address - Country:US
Mailing Address - Phone:317-513-6192
Mailing Address - Fax:
Practice Address - Street 1:12645 TEACUP WAY
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46235-6115
Practice Address - Country:US
Practice Address - Phone:317-513-6192
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist