Provider Demographics
NPI:1285037606
Name:MCCULLOUGH, KECIA LEE (CASAC MASTERS, LMSW)
Entity type:Individual
Prefix:
First Name:KECIA
Middle Name:LEE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:CASAC MASTERS, LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 GILMORE ST
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14605-1309
Mailing Address - Country:US
Mailing Address - Phone:585-233-9794
Mailing Address - Fax:
Practice Address - Street 1:227 THORN AVE
Practice Address - Street 2:
Practice Address - City:ORCHARD PARK
Practice Address - State:NY
Practice Address - Zip Code:14127-2600
Practice Address - Country:US
Practice Address - Phone:716-662-2040
Practice Address - Fax:716-662-0019
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY28786101YA0400X
NY0971261041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)