Basic Information
| Provider Information | |||||||||
| NPI: | 1114092590 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOCH | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | ANN | ||||||||
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| Credential: | LCSW | ||||||||
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| Mailing Information | |||||||||
| Address1: | 117 W BUNNY AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934582805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393474 | ||||||||
| FaxNumber: | 8057393982 | ||||||||
| Practice Location | |||||||||
| Address1: | 316 S STRATFORD AVE | ||||||||
| Address2: | SUITE B | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 934545908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8053328446 | ||||||||
| FaxNumber: | 8053328173 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/21/2006 | ||||||||
| LastUpdateDate: | 01/14/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | LCS 16790 | CA | Y | Behavioral Health & Social Service Providers | Social Worker |
ID Information
| ID | Type | State | Issuer | Description | FHC03884F | 05 | CA | MEDICAID | LCS 16790 | 01 | CA | BBSE | OTHER | FHC70593F | 05 | CA | MEDICAID |