Provider Demographics
NPI:1205916129
Name:MCCULLOUGH, DONNA (PHD)
Entity type:Individual
Prefix:
First Name:DONNA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:23121 PLAZA POINTE DR
Mailing Address - Street 2:SUITE 108
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92653-1461
Mailing Address - Country:US
Mailing Address - Phone:949-246-7724
Mailing Address - Fax:714-899-4275
Practice Address - Street 1:23121 PLAZA POINTE DR
Practice Address - Street 2:SUITE 108
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92653-1461
Practice Address - Country:US
Practice Address - Phone:949-246-7724
Practice Address - Fax:714-899-4275
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-16
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPSY14793103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP53670Medicare UPIN