Provider Demographics
NPI:1841670957
Name:MCCULLOUGH, KIARA JANAY
Entity type:Individual
Prefix:MISS
First Name:KIARA
Middle Name:JANAY
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 NE 13TH ST
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73117-5221
Mailing Address - Country:US
Mailing Address - Phone:405-535-4402
Mailing Address - Fax:
Practice Address - Street 1:310 NE 28TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73105-2806
Practice Address - Country:US
Practice Address - Phone:405-889-6822
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-03
Last Update Date:2015-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health