Provider Demographics
NPI:1063126969
Name:MCCULLOUGH, LAURA M
Entity type:Individual
Prefix:
First Name:LAURA
Middle Name:M
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2140 SEWALL BROOK RD
Mailing Address - Street 2:
Mailing Address - City:BETHEL
Mailing Address - State:VT
Mailing Address - Zip Code:05032-4520
Mailing Address - Country:US
Mailing Address - Phone:802-359-3745
Mailing Address - Fax:
Practice Address - Street 1:2140 SEWALL BROOK RD
Practice Address - Street 2:
Practice Address - City:BETHEL
Practice Address - State:VT
Practice Address - Zip Code:05032-4520
Practice Address - Country:US
Practice Address - Phone:802-359-3745
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-06
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT073.0900239224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant