Provider Demographics
NPI:1699057778
Name:MCCULLOUGH, MARY M (AUD)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:M
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3661 S MIAMI AVE
Mailing Address - Street 2:SUITE 409
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-4236
Mailing Address - Country:US
Mailing Address - Phone:305-854-5971
Mailing Address - Fax:
Practice Address - Street 1:3661 S MIAMI AVE
Practice Address - Street 2:SUITE 409
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-4236
Practice Address - Country:US
Practice Address - Phone:305-854-5971
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAY1703231H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist