MEDICARE: MS. CELEDIA EMMA MCCULLOUGH BA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	103K00000X	Behavior Analyst	1-17-27097	FL
2	103K00000X	Behavior Analyst

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1205179488
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. CELEDIA EMMA MCCULLOUGH BA

Provider Business Mailing Address
First Line	:	300 INTERNATIONAL PKWY STE 200
Second Line	:
City	:	LAKE MARY
State	:	FL
Zip	:	32746-5028
Country	:	US
Telephone Number	:	407-915-7729
Fax Number	:	407-588-6294

Provider Business Practice Location Address
First Line	:	2868 MAHAN DR UNIT 252627
Second Line	:
City	:	TALLAHASSEE
State	:	FL
Zip	:	32308-5468
Country	:	US
Telephone Number	:	850-391-6060
Fax Number	:	850-692-6206

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/05/2013
Last Update Date	:	08/21/2023

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