Provider Demographics
NPI:1740671197
Name:MCCULLOCH, DEANNA MARIE (LCPC)
Entity type:Individual
Prefix:DR
First Name:DEANNA
Middle Name:MARIE
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:LCPC
Other - Prefix:
Other - First Name:DEANNA
Other - Middle Name:MARIE
Other - Last Name:MEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:600 CENTRAL AVE STE 302
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:MT
Mailing Address - Zip Code:59401-3141
Mailing Address - Country:US
Mailing Address - Phone:719-661-7723
Mailing Address - Fax:
Practice Address - Street 1:600 CENTRAL AVE STE 302
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:MT
Practice Address - Zip Code:59401-3141
Practice Address - Country:US
Practice Address - Phone:406-201-1485
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-06
Last Update Date:2019-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COLPC.0012063101YM0800X
MTSWP-LCPC-LIC-11614101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT0MT0751420OtherBLUE CROSS-SHIELD OF MONTANA