Provider Demographics
NPI:1205349743
Name:MCCULLOUGH, KATY ROSE
Entity type:Individual
Prefix:MRS
First Name:KATY
Middle Name:ROSE
Last Name:MCCULLOUGH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7540 S 86TH AVE
Mailing Address - Street 2:
Mailing Address - City:JUSTICE
Mailing Address - State:IL
Mailing Address - Zip Code:60458-1168
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7540 S 86TH AVE
Practice Address - Street 2:
Practice Address - City:JUSTICE
Practice Address - State:IL
Practice Address - Zip Code:60458-1168
Practice Address - Country:US
Practice Address - Phone:708-496-8700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-07
Last Update Date:2017-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103TS0200XBehavioral Health & Social Service ProvidersPsychologistSchool