Provider Demographics
NPI:1669290441
Name:MCCULLOCH, MAURISSA NICOLE (LPC)
Entity type:Individual
Prefix:
First Name:MAURISSA
Middle Name:NICOLE
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:LPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 WOODLAND CREEK WAY
Mailing Address - Street 2:
Mailing Address - City:TRAVELERS REST
Mailing Address - State:SC
Mailing Address - Zip Code:29690-8490
Mailing Address - Country:US
Mailing Address - Phone:864-640-6825
Mailing Address - Fax:
Practice Address - Street 1:108 WOODLAND CREEK WAY
Practice Address - Street 2:
Practice Address - City:TRAVELERS REST
Practice Address - State:SC
Practice Address - Zip Code:29690-8490
Practice Address - Country:US
Practice Address - Phone:864-640-6825
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-30
Last Update Date:2024-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC10294101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional