Provider Demographics
NPI:1861165094
Name:MCCULLOUGH, ZAQUES J
Entity type:Individual
Prefix:
First Name:ZAQUES
Middle Name:J
Last Name:MCCULLOUGH
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 HURSTON WAY
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27405-2948
Mailing Address - Country:US
Mailing Address - Phone:252-375-0694
Mailing Address - Fax:
Practice Address - Street 1:439 US HIGHWAY 158 W
Practice Address - Street 2:
Practice Address - City:YANCEYVILLE
Practice Address - State:NC
Practice Address - Zip Code:27379-8304
Practice Address - Country:US
Practice Address - Phone:336-694-9331
Practice Address - Fax:336-694-7511
Is Sole Proprietor?:No
Enumeration Date:2021-07-25
Last Update Date:2023-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCP0162241041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical