MEDICARE: DR. DEANNA MARIE MCCULLOCH LCPC

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	101YM0800X	Mental Health Counselor	LPC.0012063	CO
2	101YP2500X	Professional Counselor	SWP-LCPC-LIC-11614	MT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0MT0751420	OTHER	MT	BLUE CROSS-SHIELD OF MONTANA

General Provider Information

NPI Number	:	1740671197
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DEANNA MARIE MCCULLOCH LCPC

Provider Business Mailing Address
First Line	:	600 CENTRAL AVE STE 302
Second Line	:
City	:	GREAT FALLS
State	:	MT
Zip	:	59401-3141
Country	:	US
Telephone Number	:	719-661-7723
Fax Number	:

Provider Business Practice Location Address
First Line	:	600 CENTRAL AVE STE 302
Second Line	:
City	:	GREAT FALLS
State	:	MT
Zip	:	59401-3141
Country	:	US
Telephone Number	:	406-201-1485
Fax Number	:

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

Provider Enumeration Date	:	02/06/2015
Last Update Date	:	03/26/2019

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