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General NPI Number Information
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NPI Number | 1073821609
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Entity Type | Individual
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Provider Name | MRS. MICHELLE DAWN MCCULLOUGH
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Gender | Female
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Dates
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Enumeration Date | 09/16/2010
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Last Update Date | 09/16/2010
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Provider Practice Location Address
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Address Line | 131 W JEFFERSON ST
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City | MADISON
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State | GA
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Zip | 30650-1368
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Country | US
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Telephone | 706-342-2242
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Fax |
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Provider Business Mailing Address
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Address Line | 1321 PROSPECT RD
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City | MADISON
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State | GA
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Zip | 30650-3151
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Country | US
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Telephone | 706-474-1625
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225700000X
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Taxonomy Name | Massage Therapist
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License Number | MT004569
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License Number State | GA
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