MEDICARE: CLARE MARIE MCCULLOUGH LPC

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	6401011510	MI

General Provider Information

NPI Number	:	1922485739
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLARE MARIE MCCULLOUGH LPC

Provider Business Mailing Address
First Line	:	477 EDGEWORTHE DR SE
Second Line	:
City	:	ADA
State	:	MI
Zip	:	49301-7809
Country	:	US
Telephone Number	:	989-429-2734
Fax Number	:

Provider Business Practice Location Address
First Line	:	477 EDGEWORTHE DR SE
Second Line	:
City	:	ADA
State	:	MI
Zip	:	49301-7809
Country	:	US
Telephone Number	:	989-429-2734
Fax Number	:

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

Provider Enumeration Date	:	04/30/2015
Last Update Date	:	04/30/2015

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