Provider Demographics
NPI:1386398980
Name:MCCULLOUGH, AMANDA JANE (PLMFT)
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:JANE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:PLMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:204 E MARKET ST
Mailing Address - Street 2:
Mailing Address - City:WARRENSBURG
Mailing Address - State:MO
Mailing Address - Zip Code:64093-1820
Mailing Address - Country:US
Mailing Address - Phone:660-864-0904
Mailing Address - Fax:
Practice Address - Street 1:807 NW 975TH RD
Practice Address - Street 2:
Practice Address - City:CENTERVIEW
Practice Address - State:MO
Practice Address - Zip Code:64019-9134
Practice Address - Country:US
Practice Address - Phone:801-390-4227
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-11
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021016981106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist