Provider Demographics
NPI:1194192021
Name:MCCULLOUGH-YRAY, MINDA (MS, ATC)
Entity type:Individual
Prefix:
First Name:MINDA
Middle Name:
Last Name:MCCULLOUGH-YRAY
Suffix:
Gender:F
Credentials:MS, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1754 SW EASY ST
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97333-1762
Mailing Address - Country:US
Mailing Address - Phone:530-632-2146
Mailing Address - Fax:
Practice Address - Street 1:1754 SW EASY ST
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97333-1762
Practice Address - Country:US
Practice Address - Phone:530-632-2146
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-26
Last Update Date:2015-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR101697842255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer