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General NPI Number Information
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NPI Number | 1417333873
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Entity Type | Individual
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Provider Name | KELLY MCCULLOUGH
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Gender | Female
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Dates
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Enumeration Date | 08/07/2015
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Last Update Date | 10/12/2018
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Provider Practice Location Address
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Address Line | 715 W COURT ST
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City | PASCO
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State | WA
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Zip | 99301-4153
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Country | US
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Telephone | 509-554-6506
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Fax | 509-546-0520
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Provider Business Mailing Address
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Address Line | 1707 W 34TH AVE
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City | KENNEWICK
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State | WA
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Zip | 99337-3838
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Country | US
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Telephone |
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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 | 101YA0400X
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Taxonomy Name | Addiction (Substance Use Disorder) Counselor
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License Number | CP60184864
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License Number State | WA
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