Provider Demographics
NPI:1194132449
Name:MCCULLOUGH, GERALD NELSON (AMA, CAADC)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:NELSON
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:AMA, CAADC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:770 RIVERSIDE AVE
Mailing Address - Street 2:STE 11
Mailing Address - City:ADRIAN
Mailing Address - State:MI
Mailing Address - Zip Code:49221-1476
Mailing Address - Country:US
Mailing Address - Phone:517-264-2244
Mailing Address - Fax:517-263-3325
Practice Address - Street 1:770 RIVERSIDE AVE
Practice Address - Street 2:STE 11
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-1476
Practice Address - Country:US
Practice Address - Phone:517-264-2244
Practice Address - Fax:517-263-3325
Is Sole Proprietor?:No
Enumeration Date:2014-07-18
Last Update Date:2014-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)