Healthcare Provider Details

I. General information

NPI: 1699039933
Provider Name (Legal Business Name): MARY IRENE MCCULLOUGH LSSP, LPC-S, NCC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/02/2012
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11757 KATY FWY STE 1300
HOUSTON TX
77079-1725
US

IV. Provider business mailing address

11757 KATY FWY STE 1300
HOUSTON TX
77079-1725
US

V. Phone/Fax

Practice location:
  • Phone: 832-429-4917
  • Fax:
Mailing address:
  • Phone: 832-429-4917
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number64887
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License Number64887
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number64887
License Number StateTX
# 4
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number64887
License Number StateTX
# 5
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number64887
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: