Provider Demographics
NPI:1124069927
Name:MCCULLOCH, TONYA L (MPT, CWS)
Entity type:Individual
Prefix:
First Name:TONYA
Middle Name:L
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:MPT, CWS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 LINE AVE
Mailing Address - Street 2:
Mailing Address - City:SHREVEPORT
Mailing Address - State:LA
Mailing Address - Zip Code:71101-4639
Mailing Address - Country:US
Mailing Address - Phone:318-213-3800
Mailing Address - Fax:318-213-3763
Practice Address - Street 1:1500 LINE AVE
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71101-4639
Practice Address - Country:US
Practice Address - Phone:318-213-3800
Practice Address - Fax:318-213-3763
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2011-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA04704225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA4H273Medicare ID - Type Unspecified
LAP00242490Medicare ID - Type UnspecifiedRAILROAD