Provider Demographics
NPI:1447067772
Name:MCCULLEY, MICHAEL QUINN (LSW)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:QUINN
Last Name:MCCULLEY
Suffix:
Gender:M
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 PHILO RD
Mailing Address - Street 2:
Mailing Address - City:URBANA
Mailing Address - State:IL
Mailing Address - Zip Code:61802-8007
Mailing Address - Country:US
Mailing Address - Phone:217-398-9066
Mailing Address - Fax:217-398-9077
Practice Address - Street 1:2001 PHILO RD
Practice Address - Street 2:
Practice Address - City:URBANA
Practice Address - State:IL
Practice Address - Zip Code:61802-8007
Practice Address - Country:US
Practice Address - Phone:217-398-9066
Practice Address - Fax:217-398-9077
Is Sole Proprietor?:No
Enumeration Date:2024-12-11
Last Update Date:2024-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL150.1155701041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical