Provider Demographics
NPI:1699422303
Name:MCCULLOUGH, MARQUITA A (LMT)
Entity type:Individual
Prefix:
First Name:MARQUITA
Middle Name:A
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11311 RICHMOND AVE STE L100A
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77082-5547
Mailing Address - Country:US
Mailing Address - Phone:702-375-9542
Mailing Address - Fax:
Practice Address - Street 1:11311 RICHMOND AVE STE L100A
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77082-5547
Practice Address - Country:US
Practice Address - Phone:702-375-9542
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-03
Last Update Date:2022-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXMT136099225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXMT136099OtherMASSAGE LICENSE