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General NPI Number Information
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NPI Number | 1801530571
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Entity Type | Individual
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Provider Name | TERRY LEE MCCULLOUGH MSW
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Gender | Male
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Dates
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Enumeration Date | 04/27/2022
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Last Update Date | 04/27/2022
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Provider Practice Location Address
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Address Line | 01546 COUNTY ROAD 665
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City | BLOOMINGDALE
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State | MI
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Zip | 49026-8756
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Country | US
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Telephone | 269-512-6163
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Fax |
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Provider Business Mailing Address
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Address Line | 01546 COUNTY ROAD 665
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City | BLOOMINGDALE
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State | MI
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Zip | 49026-8756
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Country | US
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Telephone | 269-512-6163
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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 | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number | 9689166
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License Number State | MI
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