Healthcare Provider Details

I. General information

NPI: 1639085483
Provider Name (Legal Business Name): KIARA MORRISSA MCCULLOUGH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2026
Last Update Date: 08/21/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12755 N. HIGHWAY CA-88
LODI CA
95240
US

IV. Provider business mailing address

1040 RIVER POINTE DR
LODI CA
95240-0554
US

V. Phone/Fax

Practice location:
  • Phone: 209-210-2300
  • Fax:
Mailing address:
  • Phone: 209-639-3864
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number9323
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: