Provider Demographics
NPI:1649246935
Name:MCCULLOCH, LISA MICHELLE (LPC)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:MICHELLE
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:KENYON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:LPC
Mailing Address - Street 1:1222 DUNLOE ROAD
Mailing Address - Street 2:
Mailing Address - City:BALLWIN
Mailing Address - State:MO
Mailing Address - Zip Code:63021
Mailing Address - Country:US
Mailing Address - Phone:636-207-1391
Mailing Address - Fax:636-207-1391
Practice Address - Street 1:14377 WOODLAKE DR
Practice Address - Street 2:SUITE 308
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017
Practice Address - Country:US
Practice Address - Phone:314-576-6493
Practice Address - Fax:314-576-7319
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001004734101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO691209OtherHEALTHLINK