Basic Information
| Provider Information | |||||||||
| NPI: | 1679751325 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MCCULLOUGH | ||||||||
| FirstName: | THOMAS | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | LPC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 483 W SEED FARM RD | ||||||||
| Address2: | NEW BEGININGS BUILDING | ||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852470038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025287149 | ||||||||
| FaxNumber: | 6025281374 | ||||||||
| Practice Location | |||||||||
| Address1: | 483 W SEED FARM RD | ||||||||
| Address2: | NEW BEGININGS BUILDING | ||||||||
| City: | SACATON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852470038 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6025287149 | ||||||||
| FaxNumber: | 6025281374 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/05/2008 | ||||||||
| LastUpdateDate: | 02/05/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | LPC0334 | AZ | Y | Behavioral Health & Social Service Providers | Counselor | Professional |
ID Information
| ID | Type | State | Issuer | Description | 346214 | 05 | AZ | MEDICAID |