Provider Demographics
NPI:1417333873
Name:MCCULLOUGH, KELLY
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:
Last Name:MCCULLOUGH
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 1:1707 W 34TH AVE
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99337-3838
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:715 W COURT ST
Practice Address - Street 2:
Practice Address - City:PASCO
Practice Address - State:WA
Practice Address - Zip Code:99301-4153
Practice Address - Country:US
Practice Address - Phone:509-554-6506
Practice Address - Fax:509-546-0520
Is Sole Proprietor?:No
Enumeration Date:2015-08-07
Last Update Date:2018-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACP60184864101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)