Provider Demographics
NPI:1457165946
Name:MCCULLY, ALYSSA ROSE
Entity type:Individual
Prefix:MS
First Name:ALYSSA
Middle Name:ROSE
Last Name:MCCULLY
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 1:118 BLOSSOM AVE
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-9563
Mailing Address - Country:US
Mailing Address - Phone:231-429-0074
Mailing Address - Fax:
Practice Address - Street 1:PO BOX 392
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49685-0392
Practice Address - Country:US
Practice Address - Phone:231-268-0007
Practice Address - Fax:231-525-3170
Is Sole Proprietor?:No
Enumeration Date:2025-02-04
Last Update Date:2025-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician