Provider Demographics
NPI:1932160488
Name:MCCULLOUGH, MARK ALLEN (LCSW)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ALLEN
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:LCSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9
Mailing Address - Street 2:211 16TH AVENUE NORTH
Mailing Address - City:NAMPA
Mailing Address - State:ID
Mailing Address - Zip Code:83653-0009
Mailing Address - Country:US
Mailing Address - Phone:208-467-4431
Mailing Address - Fax:208-467-7684
Practice Address - Street 1:5400 W FRANKLIN ROAD
Practice Address - Street 2:SUITE H
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705
Practice Address - Country:US
Practice Address - Phone:208-345-1170
Practice Address - Fax:208-345-3502
Is Sole Proprietor?:No
Enumeration Date:2006-03-31
Last Update Date:2008-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDLCSW6961041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1690636OtherCIGNA MEDICARE