Provider Demographics
NPI:1356466502
Name:MCCULLUM, ANITA (PTA)
Entity type:Individual
Prefix:MRS
First Name:ANITA
Middle Name:
Last Name:MCCULLUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11855 H G TRUEMAN RD
Mailing Address - Street 2:GATEAU PHYSICAL THERAPY
Mailing Address - City:LUSBY
Mailing Address - State:MD
Mailing Address - Zip Code:20657
Mailing Address - Country:US
Mailing Address - Phone:410-326-3432
Mailing Address - Fax:410-326-2493
Practice Address - Street 1:11855 H G TRUEMAN RD
Practice Address - Street 2:GATEAU PHYSICAL THERAPY
Practice Address - City:LUSBY
Practice Address - State:MD
Practice Address - Zip Code:20657
Practice Address - Country:US
Practice Address - Phone:410-326-3432
Practice Address - Fax:410-326-2493
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA1591225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant