Provider Demographics
NPI:1356570337
Name:MCCULLY, PATRICK WAYNE
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:WAYNE
Last Name:MCCULLY
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 1:2235 CHALLENGER WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5458
Mailing Address - Country:US
Mailing Address - Phone:707-565-5008
Mailing Address - Fax:707-565-4814
Practice Address - Street 1:2235 CHALLENGER WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5458
Practice Address - Country:US
Practice Address - Phone:707-565-5008
Practice Address - Fax:707-565-4814
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-10
Last Update Date:2025-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAMFT152291106H00000X
101Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101Y00000XBehavioral Health & Social Service ProvidersCounselor
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist