MEDICARE: BETH MADISON MCCULLEN LMHC

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	101YM0800X	Mental Health Counselor	MH5752	FL

General Provider Information

NPI Number	:	1588058804
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BETH MADISON MCCULLEN LMHC

Provider Business Mailing Address
First Line	:	1791 HAMMOCK CT
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-5608
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2384 SADLER RD
Second Line	:
City	:	FERNANDINA BEACH
State	:	FL
Zip	:	32034-4555
Country	:	US
Telephone Number	:	904-463-9226
Fax Number	:

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

Provider Enumeration Date	:	03/25/2015
Last Update Date	:	03/25/2015

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