Provider Demographics
NPI:1073821609
Name:MCCULLOUGH, MICHELLE DAWN
Entity type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:DAWN
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MICHELLE
Other - Middle Name:DAWN
Other - Last Name:JERNIGAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1321 PROSPECT RD
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:GA
Mailing Address - Zip Code:30650-3151
Mailing Address - Country:US
Mailing Address - Phone:706-474-1625
Mailing Address - Fax:
Practice Address - Street 1:131 W JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:GA
Practice Address - Zip Code:30650-1368
Practice Address - Country:US
Practice Address - Phone:706-342-2242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-09-16
Last Update Date:2010-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAMT004569225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist