Provider Demographics
NPI:1255769360
Name:MCCULLY, ANTOINETTE
Entity type:Individual
Prefix:
First Name:ANTOINETTE
Middle Name:
Last Name:MCCULLY
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:PO BOX 291455
Mailing Address - Street 2:
Mailing Address - City:PHELAN
Mailing Address - State:CA
Mailing Address - Zip Code:92329-1455
Mailing Address - Country:US
Mailing Address - Phone:760-780-7091
Mailing Address - Fax:
Practice Address - Street 1:13901 AMARGOSA RD
Practice Address - Street 2:SUITE 2
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-2409
Practice Address - Country:US
Practice Address - Phone:760-512-1925
Practice Address - Fax:626-737-1095
Is Sole Proprietor?:No
Enumeration Date:2013-10-29
Last Update Date:2013-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst