Provider Demographics
NPI:1720256555
Name:MCCULLOUGH, GARY R (CDP)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:R
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:CDP
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:627 5TH ST
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:MUKILTEO
Mailing Address - State:WA
Mailing Address - Zip Code:98275-1580
Mailing Address - Country:US
Mailing Address - Phone:425-328-9528
Mailing Address - Fax:425-786-9276
Practice Address - Street 1:627 5TH ST
Practice Address - Street 2:SUITE 100A
Practice Address - City:MUKILTEO
Practice Address - State:WA
Practice Address - Zip Code:98275-1580
Practice Address - Country:US
Practice Address - Phone:425-290-5757
Practice Address - Fax:425-786-9276
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-14
Last Update Date:2014-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP00001723101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)