Provider Demographics
NPI:1295131449
Name:MCCULLOUGH, ERICA MARIE (LMFT)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:MARIE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1376 E ROSEMARY TRL
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-1157
Mailing Address - Country:US
Mailing Address - Phone:623-300-8181
Mailing Address - Fax:
Practice Address - Street 1:6344 E BROADWAY RD STE 107
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1634
Practice Address - Country:US
Practice Address - Phone:480-788-2220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-11-17
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLMFT16250106H00000X
171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family TherapistGroup - Single Specialty