MEDICARE: MRS. DEBORAH MCCULLOCH LCSW

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	104100000X	Social Worker		IN

General Provider Information

NPI Number	:	1417083486
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DEBORAH MCCULLOCH LCSW

Provider Business Mailing Address
First Line	:	11232 BITTERSWEET CREEK RUN
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46814-3286
Country	:	US
Telephone Number	:	260-436-8053
Fax Number	:

Provider Business Practice Location Address
First Line	:	3737 LAKE AVE
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-5554
Country	:	US
Telephone Number	:	260-422-1680
Fax Number	:	260-422-1555

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

Provider Enumeration Date	:	02/26/2007
Last Update Date	:	07/08/2007

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