MEDICARE: DR. MARY IRENE MCCULLOUGH LSSP, LPC-S, NCC

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	101Y00000X	Counselor	64887	TX
2	101YP2500X	Professional Counselor	64887	TX
3	101YS0200X	School Counselor	64887	TX
4	101YM0800X	Mental Health Counselor	64887	TX
5	251B00000X	Case Management Agency	64887	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1699039933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARY IRENE MCCULLOUGH LSSP, LPC-S, NCC

Provider Business Mailing Address
First Line	:	11757 KATY FWY STE 1300
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77079-1725
Country	:	US
Telephone Number	:	832-429-4917
Fax Number	:

Provider Business Practice Location Address
First Line	:	11757 KATY FWY STE 1300
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77079-1725
Country	:	US
Telephone Number	:	832-429-4917
Fax Number	:

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

Provider Enumeration Date	:	07/02/2012
Last Update Date	:	07/22/2016

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