Provider Demographics
NPI:1336605005
Name:MCCULLOUGH-LIST, MARY ELLEN (RBT)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:MCCULLOUGH-LIST
Suffix:
Gender:F
Credentials:RBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7552 NAVARRE PKWY UNIT 36
Mailing Address - Street 2:
Mailing Address - City:NAVARRE
Mailing Address - State:FL
Mailing Address - Zip Code:32566-7309
Mailing Address - Country:US
Mailing Address - Phone:509-394-1908
Mailing Address - Fax:
Practice Address - Street 1:7552 NAVARRE PKWY UNIT 36
Practice Address - Street 2:
Practice Address - City:NAVARRE
Practice Address - State:FL
Practice Address - Zip Code:32566-7309
Practice Address - Country:US
Practice Address - Phone:850-939-4190
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-18
Last Update Date:2022-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RBT-18--72833106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
RBT-18-72833OtherREGISTERED BEHAVIOR TECHNICIAN CERTIFICATION