Provider Demographics
NPI:1669699658
Name:MCCULLOUGH, PAMELA S (MED CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:PAMELA
Middle Name:S
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MED CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9 LACRUE STREET
Mailing Address - Street 2:SUITE 210
Mailing Address - City:CONCORDVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:19331
Mailing Address - Country:US
Mailing Address - Phone:800-578-7906
Mailing Address - Fax:
Practice Address - Street 1:9 LACRUE STREET
Practice Address - Street 2:SUITE 210
Practice Address - City:CONCORDVILLE
Practice Address - State:PA
Practice Address - Zip Code:19331
Practice Address - Country:US
Practice Address - Phone:800-578-7906
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GASLP000161235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist