Healthcare Provider Details

I. General information

NPI: 1497579874
Provider Name (Legal Business Name): KECIA L MCCULLOUGH LCSW PSYCHOTHERAPY SERVICES PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/12/2024
Last Update Date: 11/12/2024
Certification Date: 11/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 GILMORE ST
ROCHESTER NY
14605-1309
US

IV. Provider business mailing address

45 GILMORE ST
ROCHESTER NY
14605-1309
US

V. Phone/Fax

Practice location:
  • Phone: 585-233-9794
  • Fax:
Mailing address:
  • Phone: 585-233-9794
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MS. KECIA LEE MCCULLOUGH
Title or Position: CLINICAL THERAPIST
Credential: LCSW
Phone: 585-233-9794