Provider Demographics
NPI:1275334070
Name:MCCULLOUGH, NICOLLE
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:208 HEWITT DR STE 103 BOX 218
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76712-6693
Mailing Address - Country:US
Mailing Address - Phone:512-686-6012
Mailing Address - Fax:512-842-7227
Practice Address - Street 1:345 OWEN LN STE 102
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-5583
Practice Address - Country:US
Practice Address - Phone:512-686-6012
Practice Address - Fax:512-842-7227
Is Sole Proprietor?:No
Enumeration Date:2025-03-19
Last Update Date:2025-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX91672101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional