Provider Demographics
NPI:1962224766
Name:MCCULLUM, HAILEY MACKENZIE (PTA)
Entity type:Individual
Prefix:
First Name:HAILEY
Middle Name:MACKENZIE
Last Name:MCCULLUM
Suffix:
Gender:F
Credentials:PTA
Other - Prefix:
Other - First Name:HAILEY
Other - Middle Name:MACKENZIE
Other - Last Name:HOPPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PTA
Mailing Address - Street 1:2860 S BRETT ST
Mailing Address - Street 2:
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85295-6016
Mailing Address - Country:US
Mailing Address - Phone:760-694-7298
Mailing Address - Fax:
Practice Address - Street 1:1337 S GILBERT RD STE 105
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85204-6074
Practice Address - Country:US
Practice Address - Phone:480-530-0890
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-31
Last Update Date:2024-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ014806225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant