MEDICARE: ANNA CHRISTINE MCCULLOCH LGSW

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	104100000X	Social Worker	19988	MN

General Provider Information

NPI Number	:	1922336247
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANNA CHRISTINE MCCULLOCH LGSW

Provider Business Mailing Address
First Line	:	1089 PORTLAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-7011
Country	:	US
Telephone Number	:	651-227-4184
Fax Number	:	651-224-5136

Provider Business Practice Location Address
First Line	:	1089 PORTLAND AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55104-7011
Country	:	US
Telephone Number	:	651-227-4184
Fax Number	:	651-224-5136

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

Provider Enumeration Date	:	11/24/2009
Last Update Date	:	11/24/2009

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