Provider Demographics
NPI:1912238965
Name:HEATHER MCCULLOCH, LMFT, LLC
Entity type:Organization
Organization Name:HEATHER MCCULLOCH, LMFT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ LMFT
Authorized Official - Prefix:MS
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCULLOCH
Authorized Official - Suffix:
Authorized Official - Credentials:MA
Authorized Official - Phone:505-661-0898
Mailing Address - Street 1:190 CENTRAL PARK SQ
Mailing Address - Street 2:SUITE 216
Mailing Address - City:LOS ALAMOS
Mailing Address - State:NM
Mailing Address - Zip Code:87544-4001
Mailing Address - Country:US
Mailing Address - Phone:505-661-8098
Mailing Address - Fax:505-662-0099
Practice Address - Street 1:190 CENTRAL PARK SQ
Practice Address - Street 2:SUITE 216
Practice Address - City:LOS ALAMOS
Practice Address - State:NM
Practice Address - Zip Code:87544-4001
Practice Address - Country:US
Practice Address - Phone:505-661-8098
Practice Address - Fax:505-662-0099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-14
Last Update Date:2010-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0107741273R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273R00000XHospital UnitsPsychiatric Unit