Provider Demographics
NPI:1104627033
Name:MCCULLY, BALEY
Entity type:Individual
Prefix:
First Name:BALEY
Middle Name:
Last Name:MCCULLY
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9784 WHIPPERWILL LN
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74014-3435
Mailing Address - Country:US
Mailing Address - Phone:918-633-1955
Mailing Address - Fax:
Practice Address - Street 1:716 E MAIN PLACE
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037
Practice Address - Country:US
Practice Address - Phone:479-318-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-24
Last Update Date:2025-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician