Provider Demographics
NPI:1396343075
Name:MCCULLOCH, STEPHANIE CHRISTINE
Entity type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:CHRISTINE
Last Name:MCCULLOCH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 DELAWARE PL APT 3
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:NJ
Mailing Address - Zip Code:07003-4771
Mailing Address - Country:US
Mailing Address - Phone:973-809-9550
Mailing Address - Fax:
Practice Address - Street 1:1157 MAIN AVE
Practice Address - Street 2:
Practice Address - City:CLIFTON
Practice Address - State:NJ
Practice Address - Zip Code:07011-2243
Practice Address - Country:US
Practice Address - Phone:973-341-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ37AC00456600101YP2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YP2500XBehavioral Health & Social Service ProvidersCounselorProfessional