Provider Demographics
NPI:1346637642
Name:MCCULLOUGH, GARY (PHD,CCC-SLP)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:PHD,CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 UNIVERSITY HALL DR
Mailing Address - Street 2:ROOM 216
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28608-2102
Mailing Address - Country:US
Mailing Address - Phone:828-262-7675
Mailing Address - Fax:828-262-7680
Practice Address - Street 1:400 UNIVERSITY HALL DR
Practice Address - Street 2:ROOM 216
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28608-2102
Practice Address - Country:US
Practice Address - Phone:828-262-7675
Practice Address - Fax:828-262-7680
Is Sole Proprietor?:No
Enumeration Date:2015-04-24
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC11215235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist