Provider Demographics
NPI:1699536813
Name:MCCULLOUGH, MADISON (LMSW)
Entity type:Individual
Prefix:
First Name:MADISON
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:LMSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3434 M 119 STE A
Mailing Address - Street 2:
Mailing Address - City:HARBOR SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49740-9373
Mailing Address - Country:US
Mailing Address - Phone:231-526-4734
Mailing Address - Fax:
Practice Address - Street 1:800 STATE ST
Practice Address - Street 2:
Practice Address - City:HARBOR SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49740-1137
Practice Address - Country:US
Practice Address - Phone:231-526-4734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-01-16
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68011176081041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical