Provider Demographics
NPI:1760294797
Name:MCCULLY, LYDIA NICOLE
Entity type:Individual
Prefix:MISS
First Name:LYDIA
Middle Name:NICOLE
Last Name:MCCULLY
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 1:4276 E 160TH ST
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44128-2415
Mailing Address - Country:US
Mailing Address - Phone:216-532-4115
Mailing Address - Fax:
Practice Address - Street 1:4276 E 160TH ST
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44128-2415
Practice Address - Country:US
Practice Address - Phone:216-532-4115
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-27
Last Update Date:2025-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician