MEDICARE: BRANDY MCCULLOUCH

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	101YP2500X	Professional Counselor

General Provider Information

NPI Number	:	1851765416
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDY MCCULLOUCH

Provider Business Mailing Address
First Line	:	708 COWBOY CROSS AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89081-6746
Country	:	US
Telephone Number	:	702-717-8705
Fax Number	:

Provider Business Practice Location Address
First Line	:	2525 DONNA ST APT A
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89030-5571
Country	:	US
Telephone Number	:	702-981-8859
Fax Number	:

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

Provider Enumeration Date	:	11/19/2015
Last Update Date	:	03/07/2018

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