Provider Demographics
NPI:1902331697
Name:MCCULLOUGH, CHASE (NLC)
Entity Type:Individual
Prefix:
First Name:CHASE
Middle Name:
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:NLC
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 45
Mailing Address - Street 2:
Mailing Address - City:VONA
Mailing Address - State:CO
Mailing Address - Zip Code:80861-0045
Mailing Address - Country:US
Mailing Address - Phone:719-349-0413
Mailing Address - Fax:
Practice Address - Street 1:1215 2ND ST
Practice Address - Street 2:
Practice Address - City:VONA
Practice Address - State:CO
Practice Address - Zip Code:80861-5002
Practice Address - Country:US
Practice Address - Phone:719-349-0413
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-01
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
104100000X
CONLC.0109962103TC1900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TC1900XBehavioral Health & Social Service ProvidersPsychologistCounseling
No104100000XBehavioral Health & Social Service ProvidersSocial Worker