MEDICARE: SUE MCCULLOCH

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	225200000X	Physical Therapy Assistant	2306602289	VA

General Provider Information

NPI Number	:	1831391192
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SUE MCCULLOCH

Provider Business Mailing Address
First Line	:	43 TERRY PL
Second Line	:
City	:	MOUNTAIN HOME
State	:	AR
Zip	:	72653-6713
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 PARKWEST CIR STE 108
Second Line	:
City	:	MIDLOTHIAN
State	:	VA
Zip	:	23114-5552
Country	:	US
Telephone Number	:	540-520-9411
Fax Number	:

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

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	07/08/2007

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Directions to “ SUE MCCULLOCH ” Practice Location

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