Provider Demographics
NPI:1801530571
Name:MCCULLOUGH, TERRY LEE (MSW)
Entity type:Individual
Prefix:MR
First Name:TERRY
Middle Name:LEE
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:MSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:01546 COUNTY ROAD 665
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49026-8756
Mailing Address - Country:US
Mailing Address - Phone:269-512-6163
Mailing Address - Fax:
Practice Address - Street 1:01546 COUNTY ROAD 665
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:MI
Practice Address - Zip Code:49026-8756
Practice Address - Country:US
Practice Address - Phone:269-512-6163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI9689166253Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care