Provider Demographics
NPI:1366986580
Name:MCCULLOUGH, KELLYN (MHP, LMFT)
Entity type:Individual
Prefix:
First Name:KELLYN
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:MHP, LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21907 64TH AVE W
Mailing Address - Street 2:SUITE 200
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043-2200
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7100 FORT DENT WAY
Practice Address - Street 2:SUITE 220
Practice Address - City:TUKWILA
Practice Address - State:WA
Practice Address - Zip Code:98188-7500
Practice Address - Country:US
Practice Address - Phone:425-640-7009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WALF60705572106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist