Provider Demographics
NPI:1063298180
Name:MCCULLOUGH, WENDY COLLEEN
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:COLLEEN
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 1:24660 LEPLEY RD
Mailing Address - Street 2:
Mailing Address - City:GAMBIER
Mailing Address - State:OH
Mailing Address - Zip Code:43022-9794
Mailing Address - Country:US
Mailing Address - Phone:740-225-6011
Mailing Address - Fax:
Practice Address - Street 1:24660 LEPLEY RD
Practice Address - Street 2:
Practice Address - City:GAMBIER
Practice Address - State:OH
Practice Address - Zip Code:43022-9794
Practice Address - Country:US
Practice Address - Phone:740-225-6011
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-05
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH103TM1800X
374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
No103TM1800XBehavioral Health & Social Service ProvidersPsychologistIntellectual & Developmental Disabilities