MEDICARE: LAURA M MCCULLOUGH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	224Z00000X	Occupational Therapy Assistant	073.0900239	VT

General Provider Information

NPI Number	:	1063126969
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA M MCCULLOUGH

Provider Business Mailing Address
First Line	:	2140 SEWALL BROOK RD
Second Line	:
City	:	BETHEL
State	:	VT
Zip	:	05032-4520
Country	:	US
Telephone Number	:	802-359-3745
Fax Number	:

Provider Business Practice Location Address
First Line	:	2140 SEWALL BROOK RD
Second Line	:
City	:	BETHEL
State	:	VT
Zip	:	05032-4520
Country	:	US
Telephone Number	:	802-359-3745
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/06/2023
Last Update Date	:	01/06/2023

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