Provider Demographics
NPI:1568704195
Name:MCCULLOUGH, LISA (DC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1822 BLACK LAKE BLVD SW STE 103
Mailing Address - Street 2:
Mailing Address - City:OLYMPIA
Mailing Address - State:WA
Mailing Address - Zip Code:98512-5628
Mailing Address - Country:US
Mailing Address - Phone:360-943-0988
Mailing Address - Fax:
Practice Address - Street 1:1822 BLACK LAKE BLVD SW STE 103
Practice Address - Street 2:
Practice Address - City:OLYMPIA
Practice Address - State:WA
Practice Address - Zip Code:98512-5628
Practice Address - Country:US
Practice Address - Phone:360-943-0988
Practice Address - Fax:615-264-8879
Is Sole Proprietor?:No
Enumeration Date:2013-03-21
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2350111N00000X
WACH61009274111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor