Provider Demographics
NPI:1215439104
Name:MCCULLOUGH, ADALYNN DANETTE (MA CCC-SLP)
Entity type:Individual
Prefix:MRS
First Name:ADALYNN
Middle Name:DANETTE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MA CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:517 VICTORIA CT
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46544-2676
Mailing Address - Country:US
Mailing Address - Phone:405-668-0069
Mailing Address - Fax:
Practice Address - Street 1:530 TANGLEWOOD LN
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-2627
Practice Address - Country:US
Practice Address - Phone:574-285-0120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-06
Last Update Date:2018-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN22006758A235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist