Provider Demographics
NPI:1124453907
Name:MCCULLOCH, KRISTA M (LSW)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:M
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 823
Mailing Address - Street 2:
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43552-0823
Mailing Address - Country:US
Mailing Address - Phone:419-491-0420
Mailing Address - Fax:567-698-7875
Practice Address - Street 1:1627 HENTHORNE DR STE C
Practice Address - Street 2:
Practice Address - City:MAUMEE
Practice Address - State:OH
Practice Address - Zip Code:43537-1370
Practice Address - Country:US
Practice Address - Phone:419-491-0420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-11
Last Update Date:2020-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHS.08007381041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2871101Medicaid