Basic Information
| Provider Information | |||||||||
| NPI: | 1417333873 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | KELLY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1707 W 34TH AVE | ||||||||
| Address2: | |||||||||
| City: | KENNEWICK | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993373838 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 715 W COURT ST | ||||||||
| Address2: | |||||||||
| City: | PASCO | ||||||||
| State: | WA | ||||||||
| PostalCode: | 993014153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5095546506 | ||||||||
| FaxNumber: | 5095460520 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/07/2015 | ||||||||
| LastUpdateDate: | 10/12/2018 | ||||||||
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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 | 101YA0400X | CP60184864 | WA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.