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General NPI Number Information
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NPI Number | 1457852725
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Entity Type | Individual
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Provider Name | NICOLE REALLE MCCULLOUGH
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Gender | Female
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Dates
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Enumeration Date | 02/22/2018
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Last Update Date | 10/02/2024
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Provider Practice Location Address
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Address Line | 15301 WARREN SHINGLE RD
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City | BEALE AFB
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State | CA
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Zip | 95903-1905
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Country | US
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Telephone | 530-634-3420
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Fax |
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Provider Business Mailing Address
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Address Line | 27440 SW VANDERSCHUERE RD
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City | HILLSBORO
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State | OR
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Zip | 97123-9439
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Country | US
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Telephone | 503-799-4114
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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 | 103TC0700X
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Taxonomy Name | Clinical Psychologist
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License Number | 14184000-2501
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License Number State | UT
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