Healthcare Provider Details

I. General information

NPI: 1699057778
Provider Name (Legal Business Name): MARY M MCCULLOUGH AUD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2011
Last Update Date: 09/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3661 S MIAMI AVE SUITE 409
MIAMI FL
33133-4236
US

IV. Provider business mailing address

3661 S MIAMI AVE SUITE 409
MIAMI FL
33133-4236
US

V. Phone/Fax

Practice location:
  • Phone: 305-854-5971
  • Fax:
Mailing address:
  • Phone: 305-854-5971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAY1703
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: