Provider Demographics
NPI:1215251962
Name:MCCULLOCH, KEYONNA SHAWNTEL (MSW)
Entity type:Individual
Prefix:
First Name:KEYONNA
Middle Name:SHAWNTEL
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:MSW
Other - Prefix:
Other - First Name:KEYONNA
Other - Middle Name:S
Other - Last Name:WITHERSPOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2045 PRIMROSE ST
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97402-1217
Mailing Address - Country:US
Mailing Address - Phone:541-731-4158
Mailing Address - Fax:
Practice Address - Street 1:2440 WILLAMETTE ST STE 201
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97405-3170
Practice Address - Country:US
Practice Address - Phone:541-321-2278
Practice Address - Fax:541-246-8826
Is Sole Proprietor?:No
Enumeration Date:2010-03-24
Last Update Date:2020-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X
ORA3534101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR5006614690Medicaid