Basic Information
| Provider Information | |||||||||
| NPI: | 1174016422 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | TIFFANY | ||||||||
| MiddleName: | VILESE | ||||||||
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| Credential: | LMFTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2365 SHARON RD APT 2 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282111653 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6784715302 | ||||||||
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| Practice Location | |||||||||
| Address1: | 5200 PARK RD STE 218B | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282093650 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8667001606 | ||||||||
| FaxNumber: | 8663385921 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2018 | ||||||||
| LastUpdateDate: | 06/10/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106H00000X | 12099A | NC | Y | Behavioral Health & Social Service Providers | Marriage & Family Therapist |
No ID Information.