Basic Information
| Provider Information | |||||||||
| NPI: | 1083994701 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | WANDA | ||||||||
| MiddleName: | GRACE | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | LCSW | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SHARP | ||||||||
| OtherFirstName: | WANDA | ||||||||
| OtherMiddleName: | GRACE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | LCSW | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 214 GRACE LN | ||||||||
| Address2: | |||||||||
| City: | FLORA | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390716005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6015002727 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 332 HIGHWAY 12 W | ||||||||
| Address2: | |||||||||
| City: | KOSCIUSKO | ||||||||
| State: | MS | ||||||||
| PostalCode: | 390903209 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6622891800 | ||||||||
| FaxNumber: | 6622899770 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/25/2011 | ||||||||
| LastUpdateDate: | 08/25/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041C0700X | C1197 | MS | Y | Behavioral Health & Social Service Providers | Social Worker | Clinical |
No ID Information.