Provider Demographics
NPI:1720047384
Name:MCCULLOUGH, SANDRA CHERYL (LCPC)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:CHERYL
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:CHERYL
Other - Last Name:FORREY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:211 16TH AVE N
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-467-7684
Practice Address - Street 1:5400 W FRANKLIN RD
Practice Address - Street 2:SUITE H
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705
Practice Address - Country:US
Practice Address - Phone:208-345-1170
Practice Address - Fax:208-345-3502
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCPC260101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional